Healthcare Provider Details

I. General information

NPI: 1215361415
Provider Name (Legal Business Name): MICHAEL WOOLDRIDGE OT-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2013
Last Update Date: 08/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 ONE PL
JONESBORO AR
72404-9335
US

IV. Provider business mailing address

40 GABRIEL WAY
SULPHUR ROCK AR
72579-9012
US

V. Phone/Fax

Practice location:
  • Phone: 870-283-4225
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A792
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: