Healthcare Provider Details

I. General information

NPI: 1013152180
Provider Name (Legal Business Name): PERSONAL THERAPY OF NORTHEAST ARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 GRANT AVE
JONESBORO AR
72401-6155
US

IV. Provider business mailing address

1801 GRANT AVE
JONESBORO AR
72401-6155
US

V. Phone/Fax

Practice location:
  • Phone: 870-974-9114
  • Fax: 870-974-9184
Mailing address:
  • Phone: 870-974-9114
  • Fax: 870-974-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License NumberI08IN178
License Number StateAR

VIII. Authorized Official

Name: MRS. GINA DEUTER
Title or Position: OWNER
Credential:
Phone: 870-974-9114