Basic Information
Provider Information | |||||||||
NPI: | 1134268865 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCORD | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | COTA/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 503 MEREDITH DR | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | AR | ||||||||
PostalCode: | 723642519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702155678 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3998 HIGHWAY 1 N | ||||||||
Address2: |   | ||||||||
City: | FORREST CITY | ||||||||
State: | AR | ||||||||
PostalCode: | 723357637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8706331737 | ||||||||
FaxNumber: | 8706331738 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2007 | ||||||||
LastUpdateDate: | 10/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OT-A364 | AR | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 143933721 | 05 | AR |   | MEDICAID |