Provider Demographics
NPI:1316417611
Name:MATHEWS, LOREN
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 S OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:MAGAZINE
Mailing Address - State:AR
Mailing Address - Zip Code:72943-5502
Mailing Address - Country:US
Mailing Address - Phone:479-495-0651
Mailing Address - Fax:
Practice Address - Street 1:BUILDING BLOCKS PEDIATRIC THERAPY
Practice Address - Street 2:806 DAN ARK CIRCLE
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-5502
Practice Address - Country:US
Practice Address - Phone:479-495-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4316225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant