Provider Demographics
NPI:1417067935
Name:PYRAMID THERAPY SERVICES, INC
Entity Type:Organization
Organization Name:PYRAMID THERAPY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUROT
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:501-208-3564
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-0025
Mailing Address - Country:US
Mailing Address - Phone:501-208-3564
Mailing Address - Fax:501-336-8235
Practice Address - Street 1:1810 WARWICK HILLS LANE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-208-3564
Practice Address - Fax:501-336-8235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR799225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C127OtherBLUE CROSS BLUE SHIELD
AR148912742Medicaid