Healthcare Provider Details

I. General information

NPI: 1659314144
Provider Name (Legal Business Name): LARA ANNE HUMPHRIES OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 OSAGE DR
NORTH LITTLE ROCK AR
72116-5119
US

IV. Provider business mailing address

1513 OSAGE DR
NORTH LITTLE ROCK AR
72116-5119
US

V. Phone/Fax

Practice location:
  • Phone: 501-539-1046
  • Fax: 501-833-0684
Mailing address:
  • Phone: 501-539-1046
  • Fax: 501-833-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR1009
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: