Provider Demographics
NPI:1619661444
Name:CALDERON, BANESSA (LPTA)
Entity Type:Individual
Prefix:
First Name:BANESSA
Middle Name:
Last Name:CALDERON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 PHOENIX AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-7939
Mailing Address - Country:US
Mailing Address - Phone:501-772-1461
Mailing Address - Fax:
Practice Address - Street 1:1821 PHOENIX AVE STE A
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-7939
Practice Address - Country:US
Practice Address - Phone:501-772-1461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4830225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant