Provider Demographics
NPI:1720284490
Name:FORTSON, LEE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:FORTSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E OAK ST
Mailing Address - Street 2:STE 1
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4644
Mailing Address - Country:US
Mailing Address - Phone:501-336-0511
Mailing Address - Fax:501-336-4037
Practice Address - Street 1:2215 E OAK ST
Practice Address - Street 2:STE 1
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4644
Practice Address - Country:US
Practice Address - Phone:501-336-0511
Practice Address - Fax:501-336-4037
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2079-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2079-COtherAR SOCIAL WORK LICENSE