=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144967076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA DIXON LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2022
-----------------------------------------------------
Last Update Date | 07/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 342 HIGHWAY 425 S
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71655-4612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-538-5414
-----------------------------------------------------
Fax | 870-224-0223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 BILL YOUNG RD
-----------------------------------------------------
City | LAKE VILLAGE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71653-7513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-866-1201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A2307029
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------