Provider Demographics
NPI:1093216400
Name:LOCUST, FONTANA (COTA/L)
Entity Type:Individual
Prefix:
First Name:FONTANA
Middle Name:
Last Name:LOCUST
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 KINGS WAY
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-5144
Mailing Address - Country:US
Mailing Address - Phone:479-430-0497
Mailing Address - Fax:
Practice Address - Street 1:700 W SHAWNTEL SMITH BLVD
Practice Address - Street 2:
Practice Address - City:MULDROW
Practice Address - State:OK
Practice Address - Zip Code:74948-4013
Practice Address - Country:US
Practice Address - Phone:918-427-7406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant