Healthcare Provider Details

I. General information

NPI: 1104041425
Provider Name (Legal Business Name): LIVING HOPE SOUTHWEST MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ARKANSAS BLVD
TEXARKANA AR
71854-2107
US

IV. Provider business mailing address

801 ARKANSAS BLVD
TEXARKANA AR
71854-2107
US

V. Phone/Fax

Practice location:
  • Phone: 870-774-4673
  • Fax: 870-774-9313
Mailing address:
  • Phone: 870-774-4673
  • Fax: 870-774-9313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberAR3925
License Number StateAR

VIII. Authorized Official

Name: MRS. CINDY L LAVASSAR
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 903-793-4673