Provider Demographics
NPI:1578081212
Name:SHEPHERD, LEANNE NICOLE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LEANNE
Middle Name:NICOLE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 BRENDA DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4734
Mailing Address - Country:US
Mailing Address - Phone:501-303-7766
Mailing Address - Fax:
Practice Address - Street 1:200 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3424
Practice Address - Country:US
Practice Address - Phone:501-847-5660
Practice Address - Fax:501-847-5662
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1267224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant