Healthcare Provider Details

I. General information

NPI: 1235572264
Provider Name (Legal Business Name): KENNETH OMALLEY OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MAIN ST STE C
HARRISON AR
72601-3535
US

IV. Provider business mailing address

PO BOX 841
HARRISON AR
72602-0841
US

V. Phone/Fax

Practice location:
  • Phone: 870-743-5573
  • Fax: 870-743-5974
Mailing address:
  • Phone: 870-743-5573
  • Fax: 870-743-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR2117
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: