Provider Demographics
NPI:1871729921
Name:LIGHT, RETA (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:RETA
Middle Name:
Last Name:LIGHT
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 MILDRED SIMPSON DR
Mailing Address - Street 2:
Mailing Address - City:NORFORK
Mailing Address - State:AR
Mailing Address - Zip Code:72658-8415
Mailing Address - Country:US
Mailing Address - Phone:870-499-7192
Mailing Address - Fax:870-499-7196
Practice Address - Street 1:161 MILDRED SIMPSON DR
Practice Address - Street 2:
Practice Address - City:NORFORK
Practice Address - State:AR
Practice Address - Zip Code:72658-8415
Practice Address - Country:US
Practice Address - Phone:870-499-7192
Practice Address - Fax:870-499-7196
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235Z00000X TAXONOMY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist