Basic Information
| Provider Information | |||||||||
| NPI: | 1003802224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAVENS | ||||||||
| FirstName: | DEIDRE | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 LANDERS RD | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721172525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017711600 | ||||||||
| FaxNumber: | 5019552252 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 JOHN F KENNEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721167309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017585555 | ||||||||
| FaxNumber: | 5017585941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 05/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT1750 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 130498721 | 05 | AR | MEDICAID |