Healthcare Provider Details

I. General information

NPI: 1922142272
Provider Name (Legal Business Name): MENDING WINGS DEVELOPMENTAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4066 N CAMBRAY DR
FAYETTEVILLE AR
72703-5049
US

IV. Provider business mailing address

4066 N CAMBRAY DR
FAYETTEVILLE AR
72703-5049
US

V. Phone/Fax

Practice location:
  • Phone: 479-283-0024
  • Fax:
Mailing address:
  • Phone: 479-283-0024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DONALD CHAD SULLIVAN
Title or Position: PRESIDENT
Credential:
Phone: 479-283-0024