Healthcare Provider Details

I. General information

NPI: 1861555005
Provider Name (Legal Business Name): DERMOTT HIGH SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 EAST SPEEDWAY
DERMOTT AR
71638
US

IV. Provider business mailing address

1022 SCOGIN DRIVE
MONTICELLO AR
71655
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-1000
  • Fax:
Mailing address:
  • Phone: 870-367-6848
  • Fax: 870-367-9877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number0901
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLEA0901
License Number StateAR

VIII. Authorized Official

Name: JEANIE DONALDSON
Title or Position: MITS SUPERVISOR
Credential:
Phone: 870-367-6848