Provider Demographics
NPI:1891179990
Name:RUNSICK, TAYLOR SCOTT (PTA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:SCOTT
Last Name:RUNSICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:LYNDSEY
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:302 EVELYN AVE E
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-3606
Mailing Address - Country:US
Mailing Address - Phone:870-208-7877
Mailing Address - Fax:
Practice Address - Street 1:661 HIGHWAY 64B
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-8506
Practice Address - Country:US
Practice Address - Phone:870-208-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3987225200000X
AR5409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR211-505-721Medicaid