Healthcare Provider Details

I. General information

NPI: 1265919864
Provider Name (Legal Business Name): DEWEY B DYKES IV LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W SUNBRIDGE DR
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 479-695-1240
  • Fax: 479-750-4843
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-4843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1712333
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: