Healthcare Provider Details

I. General information

NPI: 1851886352
Provider Name (Legal Business Name): LITTLE ROCK COMMUNITY MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N. UNIVERSITY
LITTLE ROCK AR
72205
US

IV. Provider business mailing address

1100 N UNIVERSITY AVE
LITTLE ROCK AR
72207-6343
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-9300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLO49916
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL049916
License Number StateAR

VIII. Authorized Official

Name: NICOLE M LEWIS
Title or Position: LPN
Credential: LPN
Phone: 501-686-9300