Basic Information
| Provider Information | |||||||||
| NPI: | 1386069961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARVAJAL | ||||||||
| FirstName: | LEAH | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4815 ABBEY GAIL DR | ||||||||
| Address2: | #1 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720349288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038263111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799681298 | ||||||||
| FaxNumber: | 4799686053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2014 | ||||||||
| LastUpdateDate: | 05/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A1401013 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.