Healthcare Provider Details

I. General information

NPI: 1770211369
Provider Name (Legal Business Name): KATELYN MOORE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S ROSE ST
SHERIDAN AR
72150-2451
US

IV. Provider business mailing address

201 S ROSE ST
SHERIDAN AR
72150-2451
US

V. Phone/Fax

Practice location:
  • Phone: 870-917-2171
  • Fax: 870-917-2161
Mailing address:
  • Phone: 870-917-2171
  • Fax: 870-917-2161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2308009
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: