Basic Information
| Provider Information | |||||||||
| NPI: | 1194134494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAMBERT | ||||||||
| FirstName: | BRENESHA | ||||||||
| MiddleName: | BRYELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAMBERT | ||||||||
| OtherFirstName: | BRENESHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LAC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1815 PLEASANT GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724057870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 PLEASANT GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724057870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2014 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/14/2019 | ||||||||
| NPIReactivationDate: | 01/30/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A1901007 | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | P2205000 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.