Healthcare Provider Details

I. General information

NPI: 1083717425
Provider Name (Legal Business Name): MARIAN EADES OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 REMINGTON COVE
LITTLE ROCK AR
72204
US

IV. Provider business mailing address

30 N. LAKE CIR.
CONWAY AR
72032
US

V. Phone/Fax

Practice location:
  • Phone: 855-556-4769
  • Fax:
Mailing address:
  • Phone: 501-329-6787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR1466
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: