Healthcare Provider Details

I. General information

NPI: 1730806522
Provider Name (Legal Business Name): ANA RODRIGUEZ LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANA RODRIGUEZ ORTIZ LAC

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 POPLAR PL
ROGERS AR
72756-4249
US

IV. Provider business mailing address

2809 FOREST HOME RD
JONESBORO AR
72401-5320
US

V. Phone/Fax

Practice location:
  • Phone: 479-372-6464
  • Fax: 479-372-6460
Mailing address:
  • Phone: 866-972-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2208012
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: