Basic Information
| Provider Information | |||||||||
| NPI: | 1689877862 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIVING HOPE SOUTHEAST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10025 W MARKHAM ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722052178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016635473 | ||||||||
| FaxNumber: | 5018011816 | ||||||||
| Practice Location | |||||||||
| Address1: | 10025 W MARKHAM ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722052178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016635473 | ||||||||
| FaxNumber: | 5018011816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | LINDSAY | ||||||||
| AuthorizedOfficialFirstName: | LYNNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OPERATIONS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5016635473 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 165404526 | 05 | AR | MEDICAID |