Healthcare Provider Details

I. General information

NPI: 1609488014
Provider Name (Legal Business Name): LAUREN LICHTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 MCKNIGHT AVE
WEST FORK AZ
72774
US

IV. Provider business mailing address

PO BOX 419
WEST FORK AR
72774-0419
US

V. Phone/Fax

Practice location:
  • Phone: 479-839-3035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: