Healthcare Provider Details

I. General information

NPI: 1336584374
Provider Name (Legal Business Name): HERITAGE THERAPY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 COUNTY ROAD 753
JONESBORO AR
72401-0232
US

IV. Provider business mailing address

940 COUNTY ROAD 753
JONESBORO AR
72401-0232
US

V. Phone/Fax

Practice location:
  • Phone: 870-219-1027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2316
License Number StateAR

VIII. Authorized Official

Name: MRS. AMANDA GAIL ESCUE
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: SLP
Phone: 870-219-1027