Provider Demographics
NPI:1033646245
Name:ABSOLUTE PEDIATRIC THERAPY
Entity type:Organization
Organization Name:ABSOLUTE PEDIATRIC THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-250-4355
Mailing Address - Street 1:2713 SE I ST STE 5
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-0078
Mailing Address - Country:US
Mailing Address - Phone:479-250-4355
Mailing Address - Fax:479-553-7954
Practice Address - Street 1:2713 SE I ST STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-0078
Practice Address - Country:US
Practice Address - Phone:479-250-4355
Practice Address - Fax:479-553-7954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR711235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR220393742Medicaid