Provider Demographics
NPI:1467864074
Name:WHITE, TAMMY (OTA/L)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 VENEZIA LN
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7458
Mailing Address - Country:US
Mailing Address - Phone:501-319-2668
Mailing Address - Fax:
Practice Address - Street 1:8109 INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4840
Practice Address - Country:US
Practice Address - Phone:501-562-5400
Practice Address - Fax:501-562-8577
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARO-T1410224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR203022721Medicaid