Provider Demographics
NPI:1063534675
Name:GATES-WINDHAM, PRINCESS ROSE (PT)
Entity type:Individual
Prefix:
First Name:PRINCESS
Middle Name:ROSE
Last Name:GATES-WINDHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 RIDGEFIELD LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-8513
Mailing Address - Country:US
Mailing Address - Phone:501-231-3977
Mailing Address - Fax:501-228-3892
Practice Address - Street 1:9720 N RODNEY PARHAM RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-6212
Practice Address - Country:US
Practice Address - Phone:501-228-3908
Practice Address - Fax:501-228-3892
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 14782251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131668721Medicaid