Provider Demographics
NPI:1174829683
Name:PATEL, VIBHA M (PTA)
Entity Type:Individual
Prefix:
First Name:VIBHA
Middle Name:M
Last Name:PATEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SANDSTONE CIR APT 7
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-7109
Mailing Address - Country:US
Mailing Address - Phone:479-498-2045
Mailing Address - Fax:
Practice Address - Street 1:1600 W 40TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6301
Practice Address - Country:US
Practice Address - Phone:870-541-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2066225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant