Provider Demographics
NPI:1144748526
Name:BALLEW, AMANDA G (LAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:G
Last Name:BALLEW
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:G
Other - Last Name:TROKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
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:479-750-4843
Practice Address - Street 1:60 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-695-1240
Practice Address - Fax:479-750-4843
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1805052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health