Provider Demographics
NPI:1457090466
Name:SOUTH WEST PEDIATRIC THERAPY
Entity type:Organization
Organization Name:SOUTH WEST PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:501-844-0453
Mailing Address - Street 1:155 SAN FELIPE RD
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71909-9726
Mailing Address - Country:US
Mailing Address - Phone:501-844-0453
Mailing Address - Fax:
Practice Address - Street 1:600 MAIN ST STE L
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-4964
Practice Address - Country:US
Practice Address - Phone:501-232-7552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR178007721Medicaid