Provider Demographics
NPI:1386069961
Name:CARVAJAL, LEAH (LAC)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:CARVAJAL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 ABBEY GAIL DR
Mailing Address - Street 2:#1
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-9288
Mailing Address - Country:US
Mailing Address - Phone:903-826-3111
Mailing Address - Fax:
Practice Address - Street 1:110 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3362
Practice Address - Country:US
Practice Address - Phone:479-968-1298
Practice Address - Fax:479-968-6053
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1401013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health