Healthcare Provider Details

I. General information

NPI: 1114473261
Provider Name (Legal Business Name): WHITNEY E MIX LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WHITNEY LASSE LAC

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 SOUTH 48TH STREET SUITE B
SPRINGDALE AR
72762
US

IV. Provider business mailing address

1672 SOUTH 48TH STREET SUITE B
SPRINGDALE AR
72762
US

V. Phone/Fax

Practice location:
  • Phone: 479-202-6300
  • Fax: 479-202-6300
Mailing address:
  • Phone: 479-202-6300
  • Fax: 479-202-6300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1608109
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1903027
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: