Provider Demographics
NPI:1831797547
Name:SULLIVENT, EMMA (PTA)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:SULLIVENT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 OUACHITA ROAD 85
Mailing Address - Street 2:
Mailing Address - City:BEARDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71720-9518
Mailing Address - Country:US
Mailing Address - Phone:870-250-1604
Mailing Address - Fax:
Practice Address - Street 1:240 OUACHITA ROAD 85
Practice Address - Street 2:
Practice Address - City:BEARDEN
Practice Address - State:AR
Practice Address - Zip Code:71720-9518
Practice Address - Country:US
Practice Address - Phone:870-250-1604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4534225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant