Healthcare Provider Details

I. General information

NPI: 1306584446
Provider Name (Legal Business Name): ADELINE KAYE GREEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ADELINE NEWHART

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 E MAIN ST
CHARLESTON AR
72933-9254
US

IV. Provider business mailing address

1811 E MAIN ST
CHARLESTON AR
72933-9254
US

V. Phone/Fax

Practice location:
  • Phone: 479-275-9150
  • Fax: 479-662-4766
Mailing address:
  • Phone: 479-275-9150
  • Fax: 479-662-4766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR4253
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: