Healthcare Provider Details

I. General information

NPI: 1558614446
Provider Name (Legal Business Name): MELISSA YVONNE BOOTH PT, DPT, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 WOODLAND HEIGHTS RD
LITTLE ROCK AR
72212-2495
US

IV. Provider business mailing address

201 DONAGHEY AVE PT CENTER SUITE 308
CONWAY AR
72035-5003
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-3600
  • Fax: 501-227-4021
Mailing address:
  • Phone: 501-450-5543
  • Fax: 501-450-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number705
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number705
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: