Provider Demographics
NPI:1073596086
Name:STEVENS, RICHARD DALE (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DALE
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 ACTIVE WAY
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-0000
Mailing Address - Country:US
Mailing Address - Phone:501-315-0984
Mailing Address - Fax:
Practice Address - Street 1:2010 ACTIVE WAY
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-0000
Practice Address - Country:US
Practice Address - Phone:501-315-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126920721Medicaid
AR126920721Medicaid