Healthcare Provider Details

I. General information

NPI: 1174816896
Provider Name (Legal Business Name): LAKESHA NICOLE MATTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAKESHA NICOLE MCLAURIN LAC

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5607 KENTUCKY RD
BENTON AR
72019-7058
US

IV. Provider business mailing address

200 N MICHIGAN AVE
CHICAGO IL
60601-5909
US

V. Phone/Fax

Practice location:
  • Phone: 501-258-9204
  • Fax:
Mailing address:
  • Phone: 312-971-3457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701012780
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number73312
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: