Healthcare Provider Details

I. General information

NPI: 1437313103
Provider Name (Legal Business Name): MARY HANSON PT ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KIDS FIRST MAGNOLIA CALHOUN RD
MAGNOLIA AR
71753
US

IV. Provider business mailing address

109 OLD EL DORADO RD
MAGNOLIA AR
71753-8415
US

V. Phone/Fax

Practice location:
  • Phone: 870-234-1597
  • Fax:
Mailing address:
  • Phone: 870-901-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2058
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: