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General NPI Number Information
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NPI Number | 1851702724
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Entity Type | Organization
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Legal Business Name | LEAD TEACH MENTOR, LLC
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Dates
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Enumeration Date | 05/14/2014
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Last Update Date | 05/14/2014
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Provider Practice Location Address
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Address Line | 575 CLUB LN SUITE 103
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City | CONWAY
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State | AR
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Zip | 72034-3681
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Country | US
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Telephone | 501-745-6644
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Fax |
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Provider Business Mailing Address
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Address Line | 1059 VISTA PARK DR SUITE B
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City | FOREST
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State | VA
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Zip | 24551-4253
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CURTIS ROBINSON
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Credential |
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Telephone | 501-745-6644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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