Provider Demographics
NPI:1760443220
Name:KIDSOURCE THERAPY
Entity Type:Organization
Organization Name:KIDSOURCE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MS PT VP
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:TINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT
Authorized Official - Phone:501-315-4415
Mailing Address - Street 1:17706 I-30
Mailing Address - Street 2:STE 3
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015
Mailing Address - Country:US
Mailing Address - Phone:501-315-4414
Mailing Address - Fax:501-315-3467
Practice Address - Street 1:17706 I-30
Practice Address - Street 2:STE 3
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015
Practice Address - Country:US
Practice Address - Phone:501-315-4414
Practice Address - Fax:501-315-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C299OtherBCBS
AR5C299OtherBCBS