Provider Demographics
NPI:1215779731
Name:WACASTER, LILLIE (LAC)
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:
Last Name:WACASTER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2803
Mailing Address - Country:US
Mailing Address - Phone:479-964-2011
Mailing Address - Fax:
Practice Address - Street 1:814 HIGDON FERRY RD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6128
Practice Address - Country:US
Practice Address - Phone:501-397-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2405013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health