Provider Demographics
NPI:1700366382
Name:WILLOUGHBY, ANNA WALKER (LAC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:WALKER
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:MARILYN
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:3201 W KEISER
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3467
Practice Address - Country:US
Practice Address - Phone:870-622-0592
Practice Address - Fax:870-622-0782
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP2500X
AR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional