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General NPI Number Information
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NPI Number | 1851768303
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Entity Type | Individual
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Provider Name | BRETT BLACK MOT, OT/L
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Gender | Male
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Dates
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Enumeration Date | 08/31/2015
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Last Update Date | 10/04/2023
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Provider Practice Location Address
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Address Line | 4497 W PECAN ST
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City | FAYETTEVILLE
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State | AR
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Zip | 72704-7909
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Country | US
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Telephone | 501-230-2050
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Fax |
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Provider Business Mailing Address
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Address Line | 405 SW BARN VALLEY RD
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City | BENTONVILLE
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State | AR
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Zip | 72712-9378
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Country | US
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Telephone | 501-230-2050
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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-A1000
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OT2023-028
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License Number State | AR
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