Basic Information
Provider Information | |||||||||
NPI: | 1679540413 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARPENTER | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | L.P.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 125 WELLNESS WAY | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719136478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016247111 | ||||||||
FaxNumber: | 5016205109 | ||||||||
Practice Location | |||||||||
Address1: | 1615 MARTIN LUTHER KING BLVD | ||||||||
Address2: |   | ||||||||
City: | MALVERN | ||||||||
State: | AR | ||||||||
PostalCode: | 72104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013325236 | ||||||||
FaxNumber: | 5016205109 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2006 | ||||||||
LastUpdateDate: | 06/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P0907043 | AR | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 116399726 | 05 | AR |   | MEDICAID |