Provider Demographics
NPI:1952792442
Name:WEITHMAN, LISA SPROULL (MS, LAC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SPROULL
Last Name:WEITHMAN
Suffix:
Gender:F
Credentials:MS, LAC
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 647
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078-0647
Mailing Address - Country:US
Mailing Address - Phone:501-259-9030
Mailing Address - Fax:
Practice Address - Street 1:2411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4211
Practice Address - Country:US
Practice Address - Phone:501-948-5402
Practice Address - Fax:501-533-6378
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1411145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health