Healthcare Provider Details

I. General information

NPI: 1598399875
Provider Name (Legal Business Name): LAKOTA KASWORM BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5704 EUPER LN STE 100
FORT SMITH AR
72903-3256
US

IV. Provider business mailing address

5704 EUPER LN STE 100
FORT SMITH AR
72903-3256
US

V. Phone/Fax

Practice location:
  • Phone: 479-242-4480
  • Fax: 405-336-3008
Mailing address:
  • Phone: 479-242-4480
  • Fax: 405-336-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-56265
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-113658
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: