Provider Demographics
NPI:1386414118
Name:KEATHLEY, LOREN KAYCI
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:KAYCI
Last Name:KEATHLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOREN
Other - Middle Name:KAYCI
Other - Last Name:DUVALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2109
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:1200 S ELMIRA AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-9646
Practice Address - Country:US
Practice Address - Phone:479-968-7118
Practice Address - Fax:479-968-8628
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A972224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant