Healthcare Provider Details

I. General information

NPI: 1558324939
Provider Name (Legal Business Name): TERRY LEN DEWITT PHD, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 OUACHITA ST. JONES SCIENCE CENTER, ROOM 426
ARKADELPHIA AR
71998-3700
US

IV. Provider business mailing address

410 OUACHITA ST. JONES SCIENCE CENTER, ROOM 426
ARKADELPHIA AR
71998-3700
US

V. Phone/Fax

Practice location:
  • Phone: 870-245-5264
  • Fax: 870-245-5241
Mailing address:
  • Phone: 870-245-5264
  • Fax: 870-245-5241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT124
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: