=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013674803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA BROOKE CARMICHAEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2021
-----------------------------------------------------
Last Update Date | 05/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 STILLWATER DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72404-9119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-932-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 DOGWOOD ST
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72437-9707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-530-6246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA1783
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------