Healthcare Provider Details

I. General information

NPI: 1205380466
Provider Name (Legal Business Name): AUDREY HUFF COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NW 4TH ST
BRYANT AR
72022-3424
US

IV. Provider business mailing address

200 NW 4TH ST
BRYANT AR
72022-3424
US

V. Phone/Fax

Practice location:
  • Phone: 501-847-5660
  • Fax: 501-847-5662
Mailing address:
  • Phone: 501-847-5660
  • Fax: 501-847-5662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1118
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: