=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073704516
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IN-SYNC PEDIATRIC THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2007
-----------------------------------------------------
Last Update Date | 05/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1109 FAYETTEVILLE ROAD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-474-6444
-----------------------------------------------------
Fax | 479-474-6446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1109 FAYETTEVILLE ROAD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-474-6444
-----------------------------------------------------
Fax | 479-474-6446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOCELYN MITCHELLE
-----------------------------------------------------
Credential | MS, OTR/L
-----------------------------------------------------
Telephone | 479-474-6444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------