Basic Information
Provider Information | |||||||||
NPI: | 1710204375 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DILLON | ||||||||
FirstName: | LANA | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, LPE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2420 LINWOOD DR. | ||||||||
Address2: | SUITE 1 | ||||||||
City: | PARAGOULD | ||||||||
State: | AR | ||||||||
PostalCode: | 724506122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702365880 | ||||||||
FaxNumber: | 8702365757 | ||||||||
Practice Location | |||||||||
Address1: | 1715 LINWOOD DR | ||||||||
Address2: |   | ||||||||
City: | PARAGOULD | ||||||||
State: | AR | ||||||||
PostalCode: | 724505820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702365880 | ||||||||
FaxNumber: | 8702365757 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2010 | ||||||||
LastUpdateDate: | 07/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P0509062 | AR | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | 07-12E | AR | N |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 172086795 | 05 | AR |   | MEDICAID |