Healthcare Provider Details

I. General information

NPI: 1760313589
Provider Name (Legal Business Name): ALLIE NICOLE MARTIN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10311 W MARKHAM ST
LITTLE ROCK AR
72205-2135
US

IV. Provider business mailing address

820 1/2 N SPRUCE ST
LITTLE ROCK AR
72205-1955
US

V. Phone/Fax

Practice location:
  • Phone: 501-781-2230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2604007
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: