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General NPI Number Information
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NPI Number | 1518507805
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Entity Type | Individual
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Provider Name | BLYTHE FLAKE COTA/L
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Gender | Female
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Dates
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Enumeration Date | 01/14/2020
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Last Update Date | 01/14/2020
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Provider Practice Location Address
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Address Line | 2801 OLD GREENWOOD RD STE 14
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City | FORT SMITH
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State | AR
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Zip | 72903-4560
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Country | US
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Telephone | 479-719-5736
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Fax | 479-430-7479
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Provider Business Mailing Address
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Address Line | 4300 ROGERS AVE STE 20
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City | FORT SMITH
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State | AR
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Zip | 72903-3152
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Country | US
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Telephone | 479-719-5736
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Fax | 479-430-7479
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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-A1398
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License Number State | AR
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