Healthcare Provider Details

I. General information

NPI: 1215779731
Provider Name (Legal Business Name): LILLIE WACASTER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 HIGDON FERRY RD
HOT SPRINGS AR
71913-6128
US

IV. Provider business mailing address

1310 W MAIN ST STE 201
RUSSELLVILLE AR
72801-2803
US

V. Phone/Fax

Practice location:
  • Phone: 501-397-1495
  • Fax:
Mailing address:
  • Phone: 479-964-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2405013
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: