Provider Demographics
NPI:1093011587
Name:BASS MCCORKLE, KIMBERLY (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:BASS MCCORKLE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 LOSTWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-2924
Mailing Address - Country:US
Mailing Address - Phone:870-403-1318
Mailing Address - Fax:
Practice Address - Street 1:2002 LOSTWOOD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-8194
Practice Address - Country:US
Practice Address - Phone:870-403-1318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR 2367225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184312721Medicaid