Healthcare Provider Details

I. General information

NPI: 1407190200
Provider Name (Legal Business Name): MELISSA LYNN LEWIS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA LYNN ENLOE MHPP

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 ARDEN LN
CONWAY AR
72034-3550
US

IV. Provider business mailing address

1765 ARDEN LN
CONWAY AR
72034-3550
US

V. Phone/Fax

Practice location:
  • Phone: 501-410-4012
  • Fax:
Mailing address:
  • Phone: 501-410-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1409130
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: