Healthcare Provider Details

I. General information

NPI: 1780452532
Provider Name (Legal Business Name): DAVID AARON MARTIN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 E MOORE AVE
SEARCY AR
72143-5099
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 870-919-6320
  • Fax: 870-972-4968
Mailing address:
  • Phone: 479-750-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2310028
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: