Provider Demographics
NPI:1124783998
Name:SQUARE ONE OT
Entity type:Organization
Organization Name:SQUARE ONE OT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OTD
Authorized Official - Phone:573-213-9467
Mailing Address - Street 1:21 CHELSEA LN
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-6522
Mailing Address - Country:US
Mailing Address - Phone:573-213-9467
Mailing Address - Fax:
Practice Address - Street 1:1202 NE MCCLAIN RD BLDG 7
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3875
Practice Address - Country:US
Practice Address - Phone:573-213-9467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty