MEDICARE: SIDEWALK THERAPY GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1396431920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIDEWALK THERAPY GROUP, LLC

Provider Business Mailing Address
First Line	:	1624 N POLK ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72207-5328
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 KAVANAUGH BLVD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-3936
Country	:	US
Telephone Number	:	501-251-7864
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KELLI REYES
Credential	:	DPT
Telephone Number	:	501-251-7864

Provider Enumeration Date	:	04/17/2023
Last Update Date	:	04/17/2023

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Directions to “SIDEWALK THERAPY GROUP, LLC ” Practice Location

Language	Start Address	Practice Location

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