Healthcare Provider Details

I. General information

NPI: 1063051373
Provider Name (Legal Business Name): GUNNER GOLDEN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 CENTRAL AVENUE STE C
HOT SPRINGS AR
71913
US

IV. Provider business mailing address

10025 W. MARKHAM STREET STE 210
LITTLE ROCK AR
72205-2178
US

V. Phone/Fax

Practice location:
  • Phone: 501-623-9220
  • Fax: 501-623-9227
Mailing address:
  • Phone: 501-663-5473
  • Fax: 501-801-1816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2608007
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: