Provider Demographics
NPI:1063008787
Name:LAINEZ ZACARIAS, ELENA MARIA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:MARIA
Last Name:LAINEZ ZACARIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:MARIA
Other - Last Name:LAINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:
Practice Address - Street 1:350 SALEM RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7525
Practice Address - Country:US
Practice Address - Phone:501-336-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARA2401030101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR259077795Medicaid