Healthcare Provider Details

I. General information

NPI: 1427783646
Provider Name (Legal Business Name): KAYLI SOSSAMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 ROGERS AVE STE 26
FORT SMITH AR
72903-3152
US

IV. Provider business mailing address

5021 N BROADWAY ST
POTEAU OK
74953-9450
US

V. Phone/Fax

Practice location:
  • Phone: 479-867-4988
  • Fax: 501-325-1255
Mailing address:
  • Phone: 479-410-7495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73536
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1-12-11455
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: