Healthcare Provider Details

I. General information

NPI: 1003350885
Provider Name (Legal Business Name): HOLLY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 CR 115
HICKORY RIDGE AR
72347-9203
US

IV. Provider business mailing address

581 CR 115
HICKORY RIDGE AR
72347-9203
US

V. Phone/Fax

Practice location:
  • Phone: 870-208-5856
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT2016-045
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: