Provider Demographics
NPI:1417396011
Name:KIDS UNLIMITED LEARNING ACADEMY OF FT. SMITH
Entity Type:Organization
Organization Name:KIDS UNLIMITED LEARNING ACADEMY OF FT. SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MCD, CCC-SLP
Authorized Official - Phone:870-761-6680
Mailing Address - Street 1:1901 PINE VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8435
Mailing Address - Country:US
Mailing Address - Phone:870-761-6680
Mailing Address - Fax:
Practice Address - Street 1:103 CHOCTAW ST
Practice Address - Street 2:
Practice Address - City:HACKETT
Practice Address - State:AR
Practice Address - Zip Code:72937-2904
Practice Address - Country:US
Practice Address - Phone:870-761-6680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 235Z00000X
AR28785261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200895742Medicaid