Healthcare Provider Details

I. General information

NPI: 1639702582
Provider Name (Legal Business Name): TAYLOR MAE MASSEY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 SCHOOL AVE
WEST FORK AR
72774-3124
US

IV. Provider business mailing address

PO DRAWER 2109
RUSSELLVILLE AR
72811
US

V. Phone/Fax

Practice location:
  • Phone: 479-839-3349
  • Fax:
Mailing address:
  • Phone: 479-967-2322
  • Fax: 479-967-2876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1589
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: