Healthcare Provider Details

I. General information

NPI: 1508539784
Provider Name (Legal Business Name): MADALYN DARE SMITH COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SCHOOL DR
MELBOURNE AR
72556-8620
US

IV. Provider business mailing address

PO BOX 72
STRAWBERRY AR
72469-0072
US

V. Phone/Fax

Practice location:
  • Phone: 870-916-2269
  • Fax:
Mailing address:
  • Phone: 870-283-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1702
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: