=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548580590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUTUMN BENNETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2010
-----------------------------------------------------
Last Update Date | 01/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 SOUTHWEST DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-932-0090
-----------------------------------------------------
Fax | 870-930-9336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 SOUTHWEST DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-932-0090
-----------------------------------------------------
Fax | 870-930-9336
-----------------------------------------------------
=====================================================
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 | PTA 2244
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OTR2670
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------