Provider Demographics
NPI:1467840538
Name:IMLER, MYSTIQUE LEIGH (LPC)
Entity Type:Individual
Prefix:
First Name:MYSTIQUE
Middle Name:LEIGH
Last Name:IMLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 W FLEEMAN STE 4
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-9171
Mailing Address - Country:US
Mailing Address - Phone:705-700-3588
Mailing Address - Fax:870-570-0359
Practice Address - Street 1:603 W FLEEMAN STE 4
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442-9171
Practice Address - Country:US
Practice Address - Phone:870-570-0358
Practice Address - Fax:870-570-0359
Is Sole Proprietor?:No
Enumeration Date:2014-12-24
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1611172101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5CB23OtherBCBS