Provider Demographics
NPI:1619386786
Name:BLAKE, BETHANY LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LYNN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10014 N RODNEY PARHAM RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-5598
Mailing Address - Country:US
Mailing Address - Phone:501-224-5454
Mailing Address - Fax:501-224-5460
Practice Address - Street 1:10014 N RODNEY PARHAM RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-5598
Practice Address - Country:US
Practice Address - Phone:501-224-5454
Practice Address - Fax:501-224-5460
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 3868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPT 3868OtherPHYSICAL THERAPY LICENSE