Provider Demographics
NPI:1932172608
Name:CREATIVE PEDIATRIC OCCUPATIONAL THERAPY, INC
Entity type:Organization
Organization Name:CREATIVE PEDIATRIC OCCUPATIONAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:479-409-5067
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:AR
Mailing Address - Zip Code:72727-0778
Mailing Address - Country:US
Mailing Address - Phone:479-409-5067
Mailing Address - Fax:479-521-5439
Practice Address - Street 1:2474 E JOYCE BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4519
Practice Address - Country:US
Practice Address - Phone:479-409-5067
Practice Address - Fax:479-521-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR582225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C353OtherBCBS GROUP NUMBER