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General NPI Number Information
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NPI Number | 1598243370
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Entity Type | Organization
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Legal Business Name | STAR PEDIATRIC THERAPY LLC
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Dates
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Enumeration Date | 08/02/2018
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Last Update Date | 08/02/2018
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Provider Practice Location Address
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Address Line | 82 W SUNBRIDGE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-1822
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Country | US
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Telephone | 479-301-2614
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Fax | 479-301-2615
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Provider Business Mailing Address
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Address Line | 82 W SUNBRIDGE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-1822
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Country | US
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Telephone | 479-301-2614
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Fax | 479-301-2615
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Authorized Official
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Title or Position | OWNER
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Name | MISTY SIMPSON
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Credential |
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Telephone | 479-301-2614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2659
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License Number State | AR
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