Provider Demographics
NPI:1720027071
Name:SPICER, KEELY ROUTH (DPT)
Entity Type:Individual
Prefix:MS
First Name:KEELY
Middle Name:ROUTH
Last Name:SPICER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 E TOWNSHIP ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4160
Mailing Address - Country:US
Mailing Address - Phone:479-790-0140
Mailing Address - Fax:479-935-9875
Practice Address - Street 1:3130 N MARKET AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3516
Practice Address - Country:US
Practice Address - Phone:479-595-0599
Practice Address - Fax:479-935-9875
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2767225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156625721Medicaid