Healthcare Provider Details

I. General information

NPI: 1528475225
Provider Name (Legal Business Name): THERESSA ROSE TAYLOR LAC, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W MAIN ST
RUSSELLVILLE AR
72801-2816
US

IV. Provider business mailing address

1310 W MAIN ST
RUSSELLVILLE AR
72801-2816
US

V. Phone/Fax

Practice location:
  • Phone: 870-647-1400
  • Fax:
Mailing address:
  • Phone: 870-647-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1407092
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: