Healthcare Provider Details

I. General information

NPI: 1215079546
Provider Name (Legal Business Name): MANDY TIGERT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/05/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 S KNOXVILLE AVE
RUSSELLVILLE AR
72801-6419
US

IV. Provider business mailing address

515 S 4TH ST
DARDANELLE AR
72834-4201
US

V. Phone/Fax

Practice location:
  • Phone: 479-346-8340
  • Fax:
Mailing address:
  • Phone: 501-339-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1503014
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: