Provider Demographics
NPI:1730320359
Name:CHEATHAM, EMILY R
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:R
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176-0333
Mailing Address - Country:US
Mailing Address - Phone:501-941-5630
Mailing Address - Fax:
Practice Address - Street 1:1500 WILSON LOOP RD
Practice Address - Street 2:
Practice Address - City:WARD
Practice Address - State:AR
Practice Address - Zip Code:72176
Practice Address - Country:US
Practice Address - Phone:501-941-5630
Practice Address - Fax:501-843-2270
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP8159235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175495721Medicaid