Provider Demographics
NPI:1497189948
Name:MCCAIN, CHASSITY ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:CHASSITY
Middle Name:ANN
Last Name:MCCAIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 COUNTRY COVE LN
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-1276
Mailing Address - Country:US
Mailing Address - Phone:479-747-5196
Mailing Address - Fax:
Practice Address - Street 1:824 SALEM RD
Practice Address - Street 2:SUITE 220
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4821
Practice Address - Country:US
Practice Address - Phone:501-932-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-01
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTA716224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR197940721Medicaid