Healthcare Provider Details

I. General information

NPI: 1427574946
Provider Name (Legal Business Name): JHARRY ANN SANTOS GUMABON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK DR STE A
HOLIDAY ISLAND AR
72631-9405
US

IV. Provider business mailing address

115 GLENWOOD CIR
CASSVILLE MO
65625-4101
US

V. Phone/Fax

Practice location:
  • Phone: 479-363-6422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1227
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: