Healthcare Provider Details

I. General information

NPI: 1679559850
Provider Name (Legal Business Name): LEISHA CALLAN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 FORT ST SUITE L
BARLING AR
72923-2045
US

IV. Provider business mailing address

201 CEDAR LN
CHARLESTON AR
72933-9499
US

V. Phone/Fax

Practice location:
  • Phone: 479-965-5086
  • Fax: 877-694-8824
Mailing address:
  • Phone: 479-965-5086
  • Fax: 877-694-8824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR275
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: