Provider Demographics
NPI:1508097858
Name:POULOS, MISTI LYNNE (LPC)
Entity Type:Individual
Prefix:DR
First Name:MISTI
Middle Name:LYNNE
Last Name:POULOS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 DORIS
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-4151
Mailing Address - Country:US
Mailing Address - Phone:214-632-4707
Mailing Address - Fax:
Practice Address - Street 1:471 DORIS
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-4151
Practice Address - Country:US
Practice Address - Phone:214-632-4707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2101143101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty