Healthcare Provider Details

I. General information

NPI: 1306356415
Provider Name (Legal Business Name): LISA HOLLAND CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6009 C W POST RD
JONESBORO AR
72401-8139
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-0228
  • Fax: 870-910-5689
Mailing address:
  • Phone: 866-641-1552
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1660
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: