Provider Demographics
NPI:1851702724
Name:LEAD TEACH MENTOR, LLC
Entity Type:Organization
Organization Name:LEAD TEACH MENTOR, LLC
Other - Org Name:THRIVEWORKS CONWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-745-6644
Mailing Address - Street 1:1059 VISTA PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 CLUB LN
Practice Address - Street 2:SUITE 103
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3681
Practice Address - Country:US
Practice Address - Phone:501-745-6644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty