Healthcare Provider Details

I. General information

NPI: 1205585288
Provider Name (Legal Business Name): KIDSPOT WALNUT RIDGE2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 03/18/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KIDSPOT 700 WEST MAIN
WALNUT RIDGE AR
72476
US

IV. Provider business mailing address

KIDSPOT 1801 GRANT AVE
JONESBORO AR
72401-6155
US

V. Phone/Fax

Practice location:
  • Phone: 870-637-5903
  • Fax: 870-637-5908
Mailing address:
  • Phone: 870-974-9114
  • Fax: 870-974-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: GINA DEUTER
Title or Position: OWNER
Credential:
Phone: 870-974-9114