Healthcare Provider Details

I. General information

NPI: 1720315088
Provider Name (Legal Business Name): BRIDGING THE GAP SPEECH THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S CHATFIELD RD
BAUXITE AR
72011-9012
US

IV. Provider business mailing address

4101 S CHATFIELD RD
BAUXITE AR
72011-9012
US

V. Phone/Fax

Practice location:
  • Phone: 501-350-2770
  • Fax:
Mailing address:
  • Phone: 501-350-2770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberSP#2130
License Number StateAR

VIII. Authorized Official

Name: CAROLE DENISE WALKER
Title or Position: SOLE OWNER
Credential: M.S., CCC-SLP
Phone: 501-350-2770