=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003233693
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEGGY BURT LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2014
-----------------------------------------------------
Last Update Date | 07/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2607 CADDO ST STE 6 AR COUNSELING & PSYCHODIAGNOSTICS, INC.
-----------------------------------------------------
City | ARKADELPHIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71923-5307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-230-8217
-----------------------------------------------------
Fax | 870-230-8201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | THE COUNSELING PLACE 2503 PINE ST STE 4
-----------------------------------------------------
City | ARKADELPHIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71923-4368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-230-8217
-----------------------------------------------------
Fax | 870-230-8201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | P1702237
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------