Healthcare Provider Details

I. General information

NPI: 1285190496
Provider Name (Legal Business Name): KATHLEEN GRACE ROSENBAUM COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 JOHNSON CIR
LOCKESBURG AR
71846-9032
US

IV. Provider business mailing address

165 JOHNSON CIR
LOCKESBURG AR
71846-9032
US

V. Phone/Fax

Practice location:
  • Phone: 870-557-6102
  • Fax:
Mailing address:
  • Phone: 870-557-6102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number215592
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number215592
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: