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General NPI Number Information
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NPI Number | 1275259970
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Entity Type | Individual
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Provider Name | BAILEY GRACE LATCHAW COTA/L
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Gender | Female
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Dates
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Enumeration Date | 10/13/2022
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Last Update Date | 07/14/2023
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Provider Practice Location Address
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Address Line | 707 N CARDINAL DR STE 4
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City | MOUNTAIN HOME
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State | AR
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Zip | 72653-3274
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Country | US
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Telephone | 870-404-0270
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Fax |
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Provider Business Mailing Address
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Address Line | 109 RYAN RD APT 3
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City | COTTER
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State | AR
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Zip | 72626-9208
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Country | US
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Telephone | 501-859-4093
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OT-A1886
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License Number State | AR
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