Basic Information
| Provider Information | |||||||||
| NPI: | 1356517981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEASLEY | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1815 PLEASANT GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 PLEASANT GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2008 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1715-M | AR | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 2550-C | AR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5TT98 | 01 | AR | BCBS | OTHER | 170153795 | 05 | AR | MEDICAID |