MEDICARE: AMY SUSAN MOUNTAIN FERENCE LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A2309010	AR

General Provider Information

NPI Number	:	1396684502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY SUSAN MOUNTAIN FERENCE LAC

Provider Business Mailing Address
First Line	:	3423 N NOTTINGHAM PL
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-6271
Country	:	US
Telephone Number	:	479-343-9023
Fax Number	:

Provider Business Practice Location Address
First Line	:	2031 N GREEN ACRES RD
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2619
Country	:	US
Telephone Number	:	406-600-1560
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2026
Last Update Date	:	03/25/2026

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Directions to “ AMY SUSAN MOUNTAIN FERENCE LAC” Practice Location

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