Provider Demographics
NPI:1003802224
Name:CRAVENS, DEIDRE LEIGH (PT)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:LEIGH
Last Name:CRAVENS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 LANDERS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-2525
Mailing Address - Country:US
Mailing Address - Phone:501-771-1600
Mailing Address - Fax:501-955-2252
Practice Address - Street 1:4540 JOHN F KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7309
Practice Address - Country:US
Practice Address - Phone:501-758-5555
Practice Address - Fax:501-758-5941
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130498721Medicaid
AR130498721Medicaid