Provider Demographics
NPI:1053361477
Name:PERSONAL THERAPY OF NORTHEAST ARKANSAS, INC.
Entity type:Organization
Organization Name:PERSONAL THERAPY OF NORTHEAST ARKANSAS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEUTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-974-9114
Mailing Address - Street 1:1801 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6155
Mailing Address - Country:US
Mailing Address - Phone:870-974-9114
Mailing Address - Fax:870-974-9184
Practice Address - Street 1:1801 GRANT AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6155
Practice Address - Country:US
Practice Address - Phone:870-974-9114
Practice Address - Fax:870-974-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157683742Medicaid
AR5F398OtherBLUE CROSS BLUE SHIELD #