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General NPI Number Information
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NPI Number | 1740753623
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Entity Type | Individual
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Provider Name | LACEY MICHELLE MEDLIN COTA/L
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Gender | Female
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Dates
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Enumeration Date | 01/03/2019
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Last Update Date | 05/02/2024
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Provider Practice Location Address
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Address Line | 5112 HARRINGTON DRIVE
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City | UNIONTOWN
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State | AR
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Zip | 72955-6932
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Country | US
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Telephone | 479-719-0906
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Fax |
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Provider Business Mailing Address
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Address Line | 2207 PARK AVE
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City | VAN BUREN
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State | AR
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Zip | 72956-6932
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Country | US
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Telephone |
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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-A1434
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License Number State | AR
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