MEDICARE: LEISHA CALLAN OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	OTR275	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5S592	OTHER	AR	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679559850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEISHA CALLAN OTR

Provider Business Mailing Address
First Line	:	201 CEDAR LN
Second Line	:
City	:	CHARLESTON
State	:	AR
Zip	:	72933-9499
Country	:	US
Telephone Number	:	479-965-5086
Fax Number	:	877-694-8824

Provider Business Practice Location Address
First Line	:	1311 FORT ST
Second Line	:	SUITE L
City	:	BARLING
State	:	AR
Zip	:	72923-2045
Country	:	US
Telephone Number	:	479-965-5086
Fax Number	:	877-694-8824

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	10/09/2012

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Directions to “ LEISHA CALLAN OTR” Practice Location

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