Provider Demographics
NPI:1417654658
Name:STANDAGE, ELIZABETH (LAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:STANDAGE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 CRIMSON CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7558
Mailing Address - Country:US
Mailing Address - Phone:501-802-0274
Mailing Address - Fax:
Practice Address - Street 1:800 EXCHANGE AVE STE 103
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7833
Practice Address - Country:US
Practice Address - Phone:501-701-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2302017101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health