Healthcare Provider Details

I. General information

NPI: 1376136630
Provider Name (Legal Business Name): KADY SELF PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 HIGHWAY 5 N
BRYANT AR
72022-7901
US

IV. Provider business mailing address

6910 HIGHWAY 5 N
BRYANT AR
72022-7901
US

V. Phone/Fax

Practice location:
  • Phone: 501-585-7580
  • Fax:
Mailing address:
  • Phone: 501-585-7580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4969
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number3310
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: