Provider Demographics
NPI:1962515841
Name:WINTERS, MISTY L (LCSW)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:L
Last Name:WINTERS
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 1:1127 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-1541
Mailing Address - Country:US
Mailing Address - Phone:870-265-3808
Mailing Address - Fax:870-265-2733
Practice Address - Street 1:1127 SECOND ST
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1541
Practice Address - Country:US
Practice Address - Phone:870-265-3808
Practice Address - Fax:870-265-2733
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2458-C1041C0700X
AR1962-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169134795Medicaid