Provider Demographics
NPI:1508024761
Name:HART, ELIZABETH ROSE (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROSE
Last Name:HART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 HAIRSTON ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3227
Mailing Address - Country:US
Mailing Address - Phone:501-450-6634
Mailing Address - Fax:
Practice Address - Street 1:1902 HAIRSTON ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3227
Practice Address - Country:US
Practice Address - Phone:501-450-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139937721Medicaid