Healthcare Provider Details

I. General information

NPI: 1659653152
Provider Name (Legal Business Name): BOBBY WAYNE ADKISON LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W INDUSTRIAL PARK RD
HARRISON AR
72601-6804
US

IV. Provider business mailing address

317 W INDUSTRIAL PARK RD
HARRISON AR
72601-6804
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1105050
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: