Healthcare Provider Details

I. General information

NPI: 1417252560
Provider Name (Legal Business Name): ROBERT SCOTT WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/16/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WILSON LOOP
WARD AR
72176
US

IV. Provider business mailing address

10310 W MARKHAM ST, SUITE 201
LITTLE ROCK AR
72205
US

V. Phone/Fax

Practice location:
  • Phone: 501-941-5630
  • Fax:
Mailing address:
  • Phone: 501-406-7910
  • Fax: 501-251-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR795
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: