Healthcare Provider Details

I. General information

NPI: 1245177427
Provider Name (Legal Business Name): EMMA YOUNGBLOOD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 LEXINGTON AVE
FORT SMITH AR
72901-3842
US

IV. Provider business mailing address

311 LEXINGTON AVE
FORT SMITH AR
72901-3842
US

V. Phone/Fax

Practice location:
  • Phone: 479-782-1444
  • Fax: 479-782-1444
Mailing address:
  • Phone: 479-782-1444
  • Fax: 479-782-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A2215
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: