Healthcare Provider Details

I. General information

NPI: 1396431920
Provider Name (Legal Business Name): SIDEWALK THERAPY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 04/17/2023
Certification Date: 04/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 KAVANAUGH BLVD
LITTLE ROCK AR
72205-3936
US

IV. Provider business mailing address

1624 N POLK ST
LITTLE ROCK AR
72207-5328
US

V. Phone/Fax

Practice location:
  • Phone: 501-251-7864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KELLI REYES
Title or Position: OWNER
Credential: DPT
Phone: 501-251-7864