Provider Demographics
NPI:1801185251
Name:DAVIDSON, TRUDY MAE (PTA)
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:MAE
Last Name:DAVIDSON
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 1:404 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-2508
Mailing Address - Country:US
Mailing Address - Phone:479-750-3535
Mailing Address - Fax:479-750-3539
Practice Address - Street 1:3291 S THOMPSON ST STE C103
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-7343
Practice Address - Country:US
Practice Address - Phone:479-750-3535
Practice Address - Fax:479-750-3539
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1659225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant