Healthcare Provider Details

I. General information

NPI: 1588959605
Provider Name (Legal Business Name): CARRIE ANN INGRAM COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 UNDERHILL RD
BEEBE AR
72012-9751
US

IV. Provider business mailing address

2001 QUALITY DR APT G10
SEARCY AR
72143-8379
US

V. Phone/Fax

Practice location:
  • Phone: 501-882-6660
  • Fax:
Mailing address:
  • Phone: 870-759-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A652
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: