MEDICARE: LIVING WELL, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	04-16P	AR
2	103TC2200X	Clinical Child & Adolescent Psychologist	04-16P	AR
3	103G00000X	Clinical Neuropsychologist	04-16P	AR

General Provider Information

NPI Number	:	1316197759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING WELL, PA

Provider Business Mailing Address
First Line	:	PO BOX 206
Second Line	:
City	:	MABELVALE
State	:	AR
Zip	:	72103-0206
Country	:	US
Telephone Number	:	501-255-1574
Fax Number	:	501-255-1446

Provider Business Practice Location Address
First Line	:	1225 BRECKENRIDGE DR
Second Line	:	SUITE 204
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-1558
Country	:	US
Telephone Number	:	501-255-1574
Fax Number	:	501-255-1446

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JODY LYNN HAGEN
Credential	:	PHD
Telephone Number	:	501-255-1574

Provider Enumeration Date	:	09/23/2008
Last Update Date	:	09/23/2008

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Directions to “LIVING WELL, PA ” Practice Location

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