Healthcare Provider Details

I. General information

NPI: 1306182746
Provider Name (Legal Business Name): HEIDI L DAUGHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20900 ROLAND HEIGHTS RD
ROLAND AR
72135-9685
US

IV. Provider business mailing address

20900 ROLAND HEIGHTS RD
ROLAND AR
72135-9685
US

V. Phone/Fax

Practice location:
  • Phone: 501-868-4760
  • Fax: 501-868-4760
Mailing address:
  • Phone: 501-868-4760
  • Fax: 501-868-4760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: