Healthcare Provider Details

I. General information

NPI: 1710369582
Provider Name (Legal Business Name): DEVONNA TILLMAN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEVONNA FRICKS LAC

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S MAIN ST
HOPE AR
71801-0000
US

IV. Provider business mailing address

829 HALBERT ST
MALVERN AR
72104-2607
US

V. Phone/Fax

Practice location:
  • Phone: 870-777-4848
  • Fax: 870-777-2410
Mailing address:
  • Phone: 501-332-4400
  • Fax: 501-332-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2009117
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: