Provider Demographics
NPI:1265674501
Name:CROW, SANDRA GAIL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:GAIL
Last Name:CROW
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 1:1207 W BLOCK ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-5355
Mailing Address - Country:US
Mailing Address - Phone:870-864-3959
Mailing Address - Fax:
Practice Address - Street 1:412 E FAULKNER ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-5802
Practice Address - Country:US
Practice Address - Phone:870-881-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 1862172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145351721Medicaid