Provider Demographics
NPI:1053030593
Name:CAMPBELL, GRACIE ANNE (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:GRACIE
Middle Name:ANNE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:GRACIE
Other - Middle Name:ANNE
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1350 S GUTENSOHN
Mailing Address - Street 2:STE. 10
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5117
Mailing Address - Country:US
Mailing Address - Phone:479-751-7122
Mailing Address - Fax:479-751-7292
Practice Address - Street 1:9 CUNNINGHAM CORNER
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-3520
Practice Address - Country:US
Practice Address - Phone:479-855-6814
Practice Address - Fax:479-855-6828
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT5222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPT5222OtherAR PHYSICAL THERAPY BOARD
AR300816721Medicaid