=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861798266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA RODEBAUGH PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2011
-----------------------------------------------------
Last Update Date | 10/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 BAY VIEW CT
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72120-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-837-5868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 619 BAY VIEW CT
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72120-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-837-5868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2349
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------