Healthcare Provider Details

I. General information

NPI: 1952449670
Provider Name (Legal Business Name): EMILY SMITH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17706 I-30 SUITE 3
BENTON AR
72019-2907
US

IV. Provider business mailing address

17706 I-30 SUITE 3
BENTON AR
72019-2907
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-4414
  • Fax: 501-315-0075
Mailing address:
  • Phone: 501-315-4414
  • Fax: 501-315-0075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2141
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: