Basic Information
| Provider Information | |||||||||
| NPI: | 1750933818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLEDGE | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 413 PLEDGER ST | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717421977 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9209 DOLLARWAY RD | ||||||||
| Address2: | |||||||||
| City: | WHITE HALL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716022616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702470800 | ||||||||
| FaxNumber: | 8702470802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2019 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OT-A919 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.