Provider Demographics
NPI:1508233875
Name:WALL, LAUREN R (PTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:R
Last Name:WALL
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 1:806 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-2655
Mailing Address - Country:US
Mailing Address - Phone:479-276-2093
Mailing Address - Fax:
Practice Address - Street 1:427 W CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-8701
Practice Address - Country:US
Practice Address - Phone:479-795-1260
Practice Address - Fax:479-795-1261
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4013225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant