Healthcare Provider Details

I. General information

NPI: 1831602895
Provider Name (Legal Business Name): KATIE RENEE DAVIDSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE RENEE DAVIDSON COTA/L

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
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: 479-755-9960
Mailing address:
  • Phone: 479-806-2879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1225
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: