Provider Demographics
NPI:1912177486
Name:REVIS, LONDA LYNNE (LCSW)
Entity Type:Individual
Prefix:
First Name:LONDA
Middle Name:LYNNE
Last Name:REVIS
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:PO BOX 9662
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-9662
Mailing Address - Country:US
Mailing Address - Phone:501-358-6695
Mailing Address - Fax:501-358-6860
Practice Address - Street 1:495 HOGAN LN STE 2
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8498
Practice Address - Country:US
Practice Address - Phone:501-358-6695
Practice Address - Fax:501-358-6860
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2212-C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker