Healthcare Provider Details

I. General information

NPI: 1548690548
Provider Name (Legal Business Name): JEREMY SCHALSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 W COLT SQUARE DR
FAYETTEVILLE AR
72703-2813
US

IV. Provider business mailing address

8323 WILSON CIR
MOUNTAINBURG AR
72946-3667
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-2740
  • Fax: 479-582-2746
Mailing address:
  • Phone: 479-965-6220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberO-T1376
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: