Provider Demographics
NPI:1275765539
Name:CROUCH, KIMBERLY NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:CROUCH
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 1:240 DALTON LN
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:AR
Mailing Address - Zip Code:72562-9400
Mailing Address - Country:US
Mailing Address - Phone:870-307-5688
Mailing Address - Fax:
Practice Address - Street 1:104 E EVERETT ST
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-3309
Practice Address - Country:US
Practice Address - Phone:870-248-1448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A568224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant