Provider Demographics
NPI:1477020659
Name:WALLACE, BROOKE (COTA/L)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:313 NATCHEZ DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9104
Mailing Address - Country:US
Mailing Address - Phone:870-253-9293
Mailing Address - Fax:
Practice Address - Street 1:1699 RED WOLF BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5442
Practice Address - Country:US
Practice Address - Phone:870-336-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1418224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR231884721Medicaid