Provider Demographics
NPI:1508304528
Name:WADE, LAURA BETH (COTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:WADE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:BETH
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2204 CHASTAIN DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-8066
Mailing Address - Country:US
Mailing Address - Phone:870-761-0602
Mailing Address - Fax:
Practice Address - Street 1:2204 CHASTAIN DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8066
Practice Address - Country:US
Practice Address - Phone:870-761-0602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant