Provider Demographics
NPI:1063674570
Name:ARKANSAS THERAPY SOURCE, LLC
Entity type:Organization
Organization Name:ARKANSAS THERAPY SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CHRISTY
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:501-249-8649
Mailing Address - Street 1:116 VALDERRAMA DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-8971
Mailing Address - Country:US
Mailing Address - Phone:501-249-8649
Mailing Address - Fax:501-315-0847
Practice Address - Street 1:116 VALDERRAMA DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-8971
Practice Address - Country:US
Practice Address - Phone:501-249-8649
Practice Address - Fax:501-315-0847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP2309235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165756742Medicaid