Healthcare Provider Details

I. General information

NPI: 1144967076
Provider Name (Legal Business Name): ANDREA DIXON LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 HIGHWAY 425 S
MONTICELLO AR
71655-4612
US

IV. Provider business mailing address

185 BILL YOUNG RD
LAKE VILLAGE AR
71653-7513
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-5414
  • Fax: 870-224-0223
Mailing address:
  • Phone: 870-866-1201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2307029
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: