Healthcare Provider Details

I. General information

NPI: 1548412893
Provider Name (Legal Business Name): LARRY OMAR DAWSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W KEISER AVE
OSCEOLA AR
72370-3467
US

IV. Provider business mailing address

1815 PLEASANT GROVE RD
JONESBORO AR
72401-7870
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 Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1608116
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1608116
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: