Provider Demographics
NPI:1518507805
Name:FLAKE, BLYTHE (COTA/L)
Entity Type:Individual
Prefix:
First Name:BLYTHE
Middle Name:
Last Name:FLAKE
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 1:4300 ROGERS AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3152
Mailing Address - Country:US
Mailing Address - Phone:479-719-5736
Mailing Address - Fax:479-430-7479
Practice Address - Street 1:2801 OLD GREENWOOD RD STE 14
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4560
Practice Address - Country:US
Practice Address - Phone:479-719-5736
Practice Address - Fax:479-430-7479
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1398224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty