Healthcare Provider Details

I. General information

NPI: 1790810414
Provider Name (Legal Business Name): KELLI KOTLARZ RAWN O.TR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLI ANN KOTLARZ OTR

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W MAIN ST
JACKSONVILLE AR
72076
US

IV. Provider business mailing address

6720 WAVERLY DRIVE
LITTLE ROCK AR
72207
US

V. Phone/Fax

Practice location:
  • Phone: 501-982-4578
  • Fax: 501-533-6326
Mailing address:
  • Phone: 501-944-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR1972
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: