Healthcare Provider Details

I. General information

NPI: 1326093279
Provider Name (Legal Business Name): TERRI LAKE BERKSHIRE MS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MUSEUM ROAD SUITE 104 CONWAY THERAPY SERVICES
CONWAY AR
72032
US

IV. Provider business mailing address

1500 MUSEUM ROAD SUITE 104 CONWAY THERAPY SERVICES
CONWAY AR
72032
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-3804
  • Fax: 801-329-0718
Mailing address:
  • Phone: 501-329-3804
  • Fax: 801-329-0718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2472
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305203594
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: