Healthcare Provider Details

I. General information

NPI: 1912177486
Provider Name (Legal Business Name): LONDA LYNNE REVIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 HOGAN LN STE 2
CONWAY AR
72034-8498
US

IV. Provider business mailing address

PO BOX 9662
CONWAY AR
72033-9662
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6695
  • Fax: 501-358-6860
Mailing address:
  • Phone: 501-358-6695
  • Fax: 501-358-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2212-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: