Provider Demographics
NPI:1326614355
Name:BOOKER, MICHAEL DAVID (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:BOOKER
Suffix:
Gender:M
Credentials:OTR/L
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 237
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:AR
Mailing Address - Zip Code:72735-0237
Mailing Address - Country:US
Mailing Address - Phone:147-946-6308
Mailing Address - Fax:
Practice Address - Street 1:418 SPRING PARK LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-9786
Practice Address - Country:US
Practice Address - Phone:479-466-3083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1090225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist