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General NPI Number Information
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NPI Number | 1194061309
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Entity Type | Organization
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Legal Business Name | SOURCE THERAPY SOLUTIONS PLLC
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Dates
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Enumeration Date | 12/14/2012
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 1721 MARTIN LUTHER KING BLVD SUITE I
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City | MALVERN
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State | AR
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Zip | 72104-2085
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Country | US
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Telephone | 501-249-5354
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Fax |
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Provider Business Mailing Address
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Address Line | 1721 MARTIN LUTHER KING BLVD SUITE I
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City | MALVERN
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State | AR
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Zip | 72104-2085
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER, CHIEF MANAGER, THERAPIST
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Name | MICHAEL ROBERT SCHOULTZ
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Credential | PT, DPT
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Telephone | 501-249-5354
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT3097
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License Number State | AR
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