Provider Demographics
NPI:1316197759
Name:LIVING WELL, PA
Entity Type:Organization
Organization Name:LIVING WELL, PA
Other - Org Name:LIVING WELL, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:501-255-1574
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103-0206
Mailing Address - Country:US
Mailing Address - Phone:501-255-1574
Mailing Address - Fax:501-255-1446
Practice Address - Street 1:1225 BRECKENRIDGE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1558
Practice Address - Country:US
Practice Address - Phone:501-255-1574
Practice Address - Fax:501-255-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04-16P103G00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty