Provider Demographics
NPI:1407190200
Name:LEWIS, MELISSA LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:ENLOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHPP
Mailing Address - Street 1:1765 ARDEN LN
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3550
Mailing Address - Country:US
Mailing Address - Phone:501-410-4012
Mailing Address - Fax:
Practice Address - Street 1:1765 ARDEN LN
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3550
Practice Address - Country:US
Practice Address - Phone:501-410-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARA1409130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator