Healthcare Provider Details

I. General information

NPI: 1083535785
Provider Name (Legal Business Name): LIVING DIFFERENTLY MENTAL HEALTH THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 HWY 64
CONWAY AR
72032
US

IV. Provider business mailing address

2420 TYLER ST
CONWAY AR
72034-3143
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-0071
  • Fax:
Mailing address:
  • Phone: 501-358-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AMY MELISSA JOHNSON
Title or Position: THERAPIST
Credential: LCSW
Phone: 501-358-0071