Provider Demographics
NPI:1790891901
Name:HOLEYFIELD, TARA SUE (PT)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:SUE
Last Name:HOLEYFIELD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 SIDON RD
Mailing Address - Street 2:
Mailing Address - City:ROSE BUD
Mailing Address - State:AR
Mailing Address - Zip Code:72137-9775
Mailing Address - Country:US
Mailing Address - Phone:501-556-4726
Mailing Address - Fax:
Practice Address - Street 1:421 CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-7035
Practice Address - Country:US
Practice Address - Phone:501-368-0947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W572OtherABCBS INDIVIDUAL NUMBER