Healthcare Provider Details

I. General information

NPI: 1447547252
Provider Name (Legal Business Name): KASEY GEHEB PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MAIN ST STE B
VAN BUREN AR
72956-4560
US

IV. Provider business mailing address

PO BOX 338
LAVACA AR
72941-0338
US

V. Phone/Fax

Practice location:
  • Phone: 479-474-6444
  • Fax: 479-474-6446
Mailing address:
  • Phone: 479-926-3993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2530
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: