Provider Demographics
NPI:1003275454
Name:BARKER, MITCHELL DAVID (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DAVID
Last Name:BARKER
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 W GUM ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-4849
Mailing Address - Country:US
Mailing Address - Phone:616-255-6609
Mailing Address - Fax:
Practice Address - Street 1:1202 NE MCCLAIN RD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3875
Practice Address - Country:US
Practice Address - Phone:616-255-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-14
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P8918235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR09141990Medicare PIN