Healthcare Provider Details

I. General information

NPI: 1518180942
Provider Name (Legal Business Name): EARL THOMAS ASHLEY MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

778 SCOGIN DR
MONTICELLO AR
71655-5729
US

IV. Provider business mailing address

212 JACI LN
MONTICELLO AR
71655-4474
US

V. Phone/Fax

Practice location:
  • Phone: 870-460-3540
  • Fax: 870-460-0531
Mailing address:
  • Phone: 870-367-9076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 1833
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: