Provider Demographics
NPI:1093534133
Name:HARRELL, LEWIS TYLER
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:TYLER
Last Name:HARRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MIRACLE KIDS SUCCESS ACADEMY
Mailing Address - Street 2:3127 SOUTHWEST DR
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MIRACLE KIDS SUCCESS ACADMEY
Practice Address - Street 2:1005 BALCOM LANE
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472
Practice Address - Country:US
Practice Address - Phone:870-418-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1704224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant