Healthcare Provider Details

I. General information

NPI: 1558593400
Provider Name (Legal Business Name): GWYN A GREGORY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GWYN DONNELL OT

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16847 BAILEY RD
WINSLOW AR
72959-9704
US

IV. Provider business mailing address

16847 BAILEY RD
WINSLOW AR
72959-9704
US

V. Phone/Fax

Practice location:
  • Phone: 402-619-1421
  • Fax:
Mailing address:
  • Phone: 402-619-1421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR603
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: