Provider Demographics
NPI:1023314432
Name:MILLS, COREY (PTA)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:MILLS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-1720
Mailing Address - Country:US
Mailing Address - Phone:501-412-3509
Mailing Address - Fax:
Practice Address - Street 1:9880 BROCKINGTON RD
Practice Address - Street 2:SUITE 147
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-3585
Practice Address - Country:US
Practice Address - Phone:501-944-7819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 1244171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1OtherNA