Healthcare Provider Details

I. General information

NPI: 1053439836
Provider Name (Legal Business Name): LISA KILCREASE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 HIGHWAY 278 W
MONTICELLO AR
71655-9663
US

IV. Provider business mailing address

136 DREAMS END
MONTICELLO AR
71655-9662
US

V. Phone/Fax

Practice location:
  • Phone: 870-367-2141
  • Fax: 870-367-2103
Mailing address:
  • Phone: 870-367-1182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2392-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: