Healthcare Provider Details

I. General information

NPI: 1740894310
Provider Name (Legal Business Name): KINLEY AUTUMN WOOD COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/01/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WHITE DR
BATESVILLE AR
72501-2001
US

IV. Provider business mailing address

2214 W BEEBE CAPPS EXPY
SEARCY AR
72143-5019
US

V. Phone/Fax

Practice location:
  • Phone: 870-569-8120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1641
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: