MEDICARE: GRACE ANNA REW LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A2512010	AR

General Provider Information

NPI Number	:	1053278788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE ANNA REW LAC

Provider Business Mailing Address
First Line	:	2400 S 48TH ST
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72762-6683
Country	:	US
Telephone Number	:	479-750-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 S 48TH ST
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72762-6683
Country	:	US
Telephone Number	:	479-750-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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Directions to “ GRACE ANNA REW LAC” Practice Location

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