Healthcare Provider Details

I. General information

NPI: 1750304986
Provider Name (Legal Business Name): KATHLEEN JOAN HARRIS CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR BUILDING 170 2K 116
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

31 LAKEVIEW DR
CONWAY AR
72032-8811
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-3277
  • Fax:
Mailing address:
  • Phone: 501-327-4966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number23894
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: