Healthcare Provider Details

I. General information

NPI: 1487930038
Provider Name (Legal Business Name): JUSTIN MATTHEW DILLON LAC, LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 N MAIN ST
HARRISON AR
72601-2914
US

IV. Provider business mailing address

3147B PRAIRIE VIEW RD
HARRISON AR
72601-5587
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-2960
  • Fax: 870-741-2965
Mailing address:
  • Phone: 870-391-1585
  • Fax: 870-741-2965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number350L
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1208060
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: