Provider Demographics
NPI:1124241120
Name:IMAGINE OCCUPATIONAL THERAPY SERVICES
Entity type:Organization
Organization Name:IMAGINE OCCUPATIONAL THERAPY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:RICHISON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:479-795-1260
Mailing Address - Street 1:1601 GREENHOUSE RD.
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9292
Mailing Address - Country:US
Mailing Address - Phone:479-795-1260
Mailing Address - Fax:479-795-1261
Practice Address - Street 1:1601 GREENHOUSE RD.
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-9292
Practice Address - Country:US
Practice Address - Phone:479-795-1260
Practice Address - Fax:479-795-1261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162908742Medicaid
AR5F709OtherBCBS