Provider Demographics
NPI:1629768536
Name:ROARK, ANDREA (LAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ROARK
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 1:1627 HIGHWAY 62 412
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9540
Mailing Address - Country:US
Mailing Address - Phone:870-257-0033
Mailing Address - Fax:
Practice Address - Street 1:1995 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9262
Practice Address - Country:US
Practice Address - Phone:870-257-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2211005101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional