Healthcare Provider Details

I. General information

NPI: 1306398151
Provider Name (Legal Business Name): KEEGAN SUTTON OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S LINCOLN STE A
LOWELL AR
72745
US

IV. Provider business mailing address

PO BOX 2109
RUSSELLVILLE AR
72811-2109
US

V. Phone/Fax

Practice location:
  • Phone: 479-770-0744
  • Fax:
Mailing address:
  • Phone: 479-967-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR2984
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: