Healthcare Provider Details

I. General information

NPI: 1316266331
Provider Name (Legal Business Name): EVA JEAN SYKES D.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 ANNEX ST
LAKE VILLAGE AR
71653-1809
US

IV. Provider business mailing address

300 HIGHWAY 142
LAKE VILLAGE AR
71653-6074
US

V. Phone/Fax

Practice location:
  • Phone: 870-265-4191
  • Fax: 870-265-4191
Mailing address:
  • Phone: 870-265-4191
  • Fax: 870-265-4192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: