Healthcare Provider Details

I. General information

NPI: 1063534675
Provider Name (Legal Business Name): PRINCESS ROSE GATES-WINDHAM P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 N RODNEY PARHAM RD
LITTLE ROCK AR
72227-6212
US

IV. Provider business mailing address

4700 RIDGEFIELD LN
LITTLE ROCK AR
72223-8513
US

V. Phone/Fax

Practice location:
  • Phone: 501-228-3908
  • Fax: 501-228-3892
Mailing address:
  • Phone: 501-231-3977
  • Fax: 501-228-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 1478
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: