Provider Demographics
NPI:1457824997
Name:BLOODWORTH, BRET TYLER (OTD R/L)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:TYLER
Last Name:BLOODWORTH
Suffix:
Gender:M
Credentials:OTD R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 OAK VISTA DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-9761
Mailing Address - Country:US
Mailing Address - Phone:870-530-3154
Mailing Address - Fax:
Practice Address - Street 1:2402 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-1963
Practice Address - Country:US
Practice Address - Phone:870-236-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR3263225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist