Healthcare Provider Details

I. General information

NPI: 1124783998
Provider Name (Legal Business Name): SQUARE ONE OT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 NE MCCLAIN RD BLDG 7
BENTONVILLE AR
72712-3875
US

IV. Provider business mailing address

21 CHELSEA LN
BELLA VISTA AR
72715-6522
US

V. Phone/Fax

Practice location:
  • Phone: 573-213-9467
  • Fax:
Mailing address:
  • Phone: 573-213-9467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATELYN ALLEN
Title or Position: OWNER
Credential: OTD
Phone: 573-213-9467