=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265936124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESTINY HARRIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2018
-----------------------------------------------------
Last Update Date | 12/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12200 WEST HAVEN DR, LITTLE ROCK
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-476-3309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10825 FINANCIAL CENTRE PKWY
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-3553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-916-9450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 202812
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------