Provider Demographics
NPI:1861725517
Name:PERSSON, MARY RUTH (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:RUTH
Last Name:PERSSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 ALDERSGATE ROAD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-687-0851
Mailing Address - Fax:501-687-0853
Practice Address - Street 1:1601 ALDERSGATE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6613
Practice Address - Country:US
Practice Address - Phone:501-687-0851
Practice Address - Fax:501-687-0853
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179776721Medicaid
AR5V266OtherBLUE CROSS BLUE SHIELD
P00848712OtherRAILROAD MEDICARE
AR5V266C883Medicare Oscar/Certification