Healthcare Provider Details

I. General information

NPI: 1962394692
Provider Name (Legal Business Name): ADDISON FAITH LANGFORD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 OLD WARREN RD
MONTICELLO AR
71655-9723
US

IV. Provider business mailing address

1200 OLD WARREN RD
MONTICELLO AR
71655-9723
US

V. Phone/Fax

Practice location:
  • Phone: 870-367-1548
  • Fax: 870-367-1383
Mailing address:
  • Phone: 870-367-1548
  • Fax: 870-367-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5046
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: