Provider Demographics
NPI:1508024134
Name:LEWIS, LARA (MCD,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MCD,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 BOLT BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-8045
Mailing Address - Country:US
Mailing Address - Phone:870-268-8393
Mailing Address - Fax:
Practice Address - Street 1:211 W HICKORY ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-2648
Practice Address - Country:US
Practice Address - Phone:870-886-3212
Practice Address - Fax:870-886-3224
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1606235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist