Provider Demographics
NPI:1376661157
Name:WILKERSON, SAMMY (LPC/LADAC)
Entity Type:Individual
Prefix:MR
First Name:SAMMY
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:LPC/LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BURNETT LN
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-9274
Mailing Address - Country:US
Mailing Address - Phone:870-723-7867
Mailing Address - Fax:
Practice Address - Street 1:706 S. BOCHARDT
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-9663
Practice Address - Country:US
Practice Address - Phone:870-723-7867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0288L101YA0400X
ARP1106045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)