Healthcare Provider Details

I. General information

NPI: 1376949875
Provider Name (Legal Business Name): MOLLIE REDDIN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-2020
  • Fax: 479-750-8967
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1412168
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: