Provider Demographics
NPI:1184655789
Name:BORRELLI, KATHY MARIE (PT OMPT)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:MARIE
Last Name:BORRELLI
Suffix:
Gender:F
Credentials:PT OMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7665
Mailing Address - Country:US
Mailing Address - Phone:501-758-1300
Mailing Address - Fax:501-758-1316
Practice Address - Street 1:4801 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8009
Practice Address - Country:US
Practice Address - Phone:501-758-1300
Practice Address - Fax:501-758-1316
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK5G239OtherMEDICARE GROUP
AR5Y753OtherBLUE CROSS/ BLUE SHEILD
AR5Y753OtherBCBS
AR168612721Medicaid
AK5G239OtherMEDICARE GROUP
AR5Y753Medicare PIN