=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326447673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHELSEA DAWN HALK PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2014
-----------------------------------------------------
Last Update Date | 08/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 661 HIGHWAY 64B
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-8506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-208-4208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 318 S COOPER ST
-----------------------------------------------------
City | CHERRY VALLEY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72324-8651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-318-9162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 3889
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------