Healthcare Provider Details

I. General information

NPI: 1104697341
Provider Name (Legal Business Name): LITTLE ROOTS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 N DAVIS ST
LAVACA AR
72941-4517
US

IV. Provider business mailing address

2941 N DAVIS ST
LAVACA AR
72941-4517
US

V. Phone/Fax

Practice location:
  • Phone: 479-806-2879
  • Fax:
Mailing address:
  • Phone: 479-806-2879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATIE RENEE DAVIDSON
Title or Position: OWNER/COTA
Credential: COTA/L
Phone: 479-806-2879