Healthcare Provider Details

I. General information

NPI: 1932172608
Provider Name (Legal Business Name): CREATIVE PEDIATRIC OCCUPATIONAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2474 E JOYCE BLVD SUITE 3
FAYETTEVILLE AR
72703-4519
US

IV. Provider business mailing address

PO BOX 778
ELKINS AR
72727-0778
US

V. Phone/Fax

Practice location:
  • Phone: 479-409-5067
  • Fax: 479-521-5439
Mailing address:
  • Phone: 479-409-5067
  • Fax: 479-521-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR582
License Number StateAR

VIII. Authorized Official

Name: MRS. ELLEN KAY BRUCE
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 479-409-5067