Healthcare Provider Details

I. General information

NPI: 1407305196
Provider Name (Legal Business Name): MARC S WILLEY OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 03/04/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 WEST MARKHAM
LITTLE ROCK AR
72205
US

IV. Provider business mailing address

2945 BAXTER DRIVE
CONWAY AR
72034
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-6353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR792
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOTR792
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: