Healthcare Provider Details

I. General information

NPI: 1346394517
Provider Name (Legal Business Name): DEBRA L. HENDERSON OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 PECAN GROVE RD
RUDY AR
72952-9026
US

IV. Provider business mailing address

3918 PECAN GROVE RD
RUDY AR
72952-9026
US

V. Phone/Fax

Practice location:
  • Phone: 479-632-6337
  • Fax: 479-632-5916
Mailing address:
  • Phone: 479-632-6337
  • Fax: 479-632-5916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR967
License Number StateAR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier149798721
Identifier TypeMEDICAID
Identifier StateAR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: