Healthcare Provider Details

I. General information

NPI: 1700366382
Provider Name (Legal Business Name): ANNA WALKER WILLOUGHBY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA MARILYN WILLOUGHBY

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W KEISER
OSCEOLA AR
72370-3467
US

IV. Provider business mailing address

1815 PLEASANT GROVE ROAD
JONESBORO AR
72405-7870
US

V. Phone/Fax

Practice location:
  • Phone: 870-622-0592
  • Fax: 870-622-0782
Mailing address:
  • Phone: 870-933-6886
  • Fax: 870-933-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: