Provider Demographics
NPI:1164405395
Name:SEBAG, JOEL DAMARILLO (RPT)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:DAMARILLO
Last Name:SEBAG
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-0841
Mailing Address - Country:US
Mailing Address - Phone:870-743-5573
Mailing Address - Fax:870-743-5974
Practice Address - Street 1:825 N MAIN ST
Practice Address - Street 2:STE 7
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2914
Practice Address - Country:US
Practice Address - Phone:870-743-5573
Practice Address - Fax:870-743-5974
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132452721Medicaid
AR5U706OtherBLUE CROSS BLUE SHIELD
AR5U706Medicare ID - Type Unspecified