Healthcare Provider Details

I. General information

NPI: 1376661157
Provider Name (Legal Business Name): SAMMY WILKERSON LPC/LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 S. BOCHARDT
MONTICELLO AR
71655-9663
US

IV. Provider business mailing address

153 BURNETT LN
MONTICELLO AR
71655-9274
US

V. Phone/Fax

Practice location:
  • Phone: 870-723-7867
  • Fax:
Mailing address:
  • Phone: 870-723-7867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0288L
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1106045
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: