=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972040566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LW BREWER WELLNESS ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2017
-----------------------------------------------------
Last Update Date | 01/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2725 CANTRELL RD STE 106
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72202-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-246-0265
-----------------------------------------------------
Fax | 501-734-8262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 CRYSTALWOOD DR
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72210-5397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-246-0265
-----------------------------------------------------
Fax | 501-734-8262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOLOGIST
-----------------------------------------------------
Name | DR. LINDA W BREWER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 501-246-0265
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 10-00P
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------