MEDICARE: MS. ESSIE L HEWETT TARGETED CASE MANAGE

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	171M00000X	Case Manager/Care Coordinator	121985746	AR
2	171M00000X	Case Manager/Care Coordinator	140168763

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	140168763	OTHER	AR	GROUP TARGETED CASE MANAGER NUMBER
2	121985746	OTHER	AR	TARGETED CASE MANAGER

General Provider Information

NPI Number	:	1154610111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ESSIE L HEWETT TARGETED CASE MANAGE

Provider Business Mailing Address
First Line	:	6311 WEST 63RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72209
Country	:	US
Telephone Number	:	501-562-2788
Fax Number	:	501-562-2784

Provider Business Practice Location Address
First Line	:	6311 WEST 83RD STREET
Second Line	:	SUITE B
City	:	LITTLE ROCK
State	:	AR
Zip	:	72214
Country	:	US
Telephone Number	:	501-562-2788
Fax Number	:	501-562-2784

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

Provider Enumeration Date	:	03/30/2011
Last Update Date	:	03/30/2011

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