1053656090 NPI number — HEATHER MICHELLE THOMPSON OTR/L

Table of content: HEATHER MICHELLE THOMPSON OTR/L (NPI 1053656090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053656090 NPI number — HEATHER MICHELLE THOMPSON OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
HEATHER
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMALLWOOD
Provider Other First Name:
HEATHER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053656090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5917 WORTH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72019-6638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-209-5553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 NW 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRYANT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72022-3424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-653-5060
Provider Business Practice Location Address Fax Number:
501-653-5931
Provider Enumeration Date:
12/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  111155 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OTR2608 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OTR2608 . This is a "ARKANSAS LIC" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 1070007 . This is a "NBCOT" identifier . This identifiers is of the category "OTHER".




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