Provider Demographics
NPI:1437342268
Name:LEWALLEN, LARRY LUCAS (LCSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:LUCAS
Last Name:LEWALLEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 S CARAWAY RD STE B1
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7336
Mailing Address - Country:US
Mailing Address - Phone:870-926-5710
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:2701 S CARAWAY RD STE B1
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7336
Practice Address - Country:US
Practice Address - Phone:870-926-5710
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4721-C1041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5GG69OtherBCBS
AR173598795Medicaid
AR173598795Medicaid