Healthcare Provider Details

I. General information

NPI: 1093534133
Provider Name (Legal Business Name): LEWIS TYLER HARRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MIRACLE KIDS SUCCESS ACADMEY 1005 BALCOM LANE
TRUMANN AR
72472
US

IV. Provider business mailing address

MIRACLE KIDS SUCCESS ACADEMY 3127 SOUTHWEST DR
JONESBORO AR
72404
US

V. Phone/Fax

Practice location:
  • Phone: 870-418-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1704
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: