Healthcare Provider Details

I. General information

NPI: 1861092603
Provider Name (Legal Business Name): ABIGAIL ROSE BERTRAM OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABIGAIL BOEHM

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W POPLAR ST
ROGERS AR
72756-4242
US

IV. Provider business mailing address

1000 W POPLAR ST
ROGERS AR
72756-4242
US

V. Phone/Fax

Practice location:
  • Phone: 479-631-7678
  • Fax:
Mailing address:
  • Phone: 479-631-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR3454
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: