Healthcare Provider Details

I. General information

NPI: 1083634224
Provider Name (Legal Business Name): BILLY JOHNSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 HWY 49 NORTH
BRINKLEY AR
72012-2122
US

IV. Provider business mailing address

19 BRENTWOOD CV
CABOT AR
72023-7301
US

V. Phone/Fax

Practice location:
  • Phone: 501-804-2304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR1322
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: