Individual
BROOKE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
1699 RED WOLF BLVD, JONESBORO, AR 72401-5442
(870) 336-0021
Mailing address
313 NATCHEZ DR, JONESBORO, AR 72404-9104
(870) 253-9293
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
OT-A1418
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
231884721
—
AR
Enumeration date
10/25/2018
Last updated
05/20/2021
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