1700245610 NPI number — KELLEY HUMBARD OT

Table of content: KELLEY HUMBARD OT (NPI 1700245610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700245610 NPI number — KELLEY HUMBARD OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUMBARD
Provider First Name:
KELLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700245610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO DRAWER 2109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-967-2322
Provider Business Mailing Address Fax Number:
479-967-2876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
272 SCHOOL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST FORK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72774-3124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-839-3349
Provider Business Practice Location Address Fax Number:
479-839-3752
Provider Enumeration Date:
02/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OTR2875 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 212700721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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