Provider Demographics
NPI:1477680833
Name:COLES, KIM (OTR-L)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:COLES
Suffix:
Gender:F
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 1:400 GREY FOX LN
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-9127
Mailing Address - Country:US
Mailing Address - Phone:870-793-3334
Mailing Address - Fax:870-793-3474
Practice Address - Street 1:2040 FITZHUGH ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7409
Practice Address - Country:US
Practice Address - Phone:870-793-3334
Practice Address - Fax:870-793-3474
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1884225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y151OtherBLUE CROSS BLUE SHIELD NU