Healthcare Provider Details

I. General information

NPI: 1710854153
Provider Name (Legal Business Name): KENLEE RAY YOUNGBLOOD COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/21/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 HAWKINS DR, SEARCY 2918 HAWKINS DR, SEARCY
SEARCY AR
72143
US

IV. Provider business mailing address

106 AMY ST
TUCKERMAN AR
72473-9321
US

V. Phone/Fax

Practice location:
  • Phone: 501-279-9255
  • Fax:
Mailing address:
  • Phone: 870-217-2680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A2166
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: