Healthcare Provider Details

I. General information

NPI: 1033194980
Provider Name (Legal Business Name): LISA G. WREN OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12018 HIGHWAY 196
TEXARKANA AR
71854-1280
US

IV. Provider business mailing address

1255 HIGHWAY 332
PRESCOTT AR
71857-9320
US

V. Phone/Fax

Practice location:
  • Phone: 870-653-4343
  • Fax:
Mailing address:
  • Phone: 870-777-6798
  • Fax: 870-887-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR1502
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: