Provider Demographics
NPI:1235572264
Name:OMALLEY, KENNETH (OTR)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:OMALLEY
Suffix:
Gender:M
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:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-0841
Mailing Address - Country:US
Mailing Address - Phone:870-743-5573
Mailing Address - Fax:870-743-5974
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:STE C
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3535
Practice Address - Country:US
Practice Address - Phone:870-743-5573
Practice Address - Fax:870-743-5974
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2117225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AROTR2117OtherOTR LICENSE