Provider Demographics
NPI:1609285923
Name:CARVAJAL, FORREST GREGORY (COTA)
Entity Type:Individual
Prefix:MR
First Name:FORREST
Middle Name:GREGORY
Last Name:CARVAJAL
Suffix:
Gender:M
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:PO BOX 952
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-0952
Mailing Address - Country:US
Mailing Address - Phone:501-365-3927
Mailing Address - Fax:501-365-3914
Practice Address - Street 1:1008 HWY 25 B
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543
Practice Address - Country:US
Practice Address - Phone:501-365-3927
Practice Address - Fax:501-365-3914
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTA886224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant