Healthcare Provider Details

I. General information

NPI: 1902052004
Provider Name (Legal Business Name): SANDRA BLAKE MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3871 SPRING ST
HOT SPRINGS AR
71901-8606
US

IV. Provider business mailing address

311 WHITTINGTON AVE
HOT SPRINGS AR
71901-3407
US

V. Phone/Fax

Practice location:
  • Phone: 501-623-3477
  • Fax:
Mailing address:
  • Phone: 501-623-3477
  • Fax: 501-624-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number057935310994E
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: