Healthcare Provider Details

I. General information

NPI: 1679754063
Provider Name (Legal Business Name): CODY WILLIS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 HIGHWAY 25B
HEBER SPRINGS AR
72543-1701
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 501-362-9426
  • Fax: 501-362-9456
Mailing address:
  • Phone: 870-347-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1402016
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA0802015
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: