Provider Demographics
NPI:1679559850
Name:CALLAN, LEISHA (OTR)
Entity Type:Individual
Prefix:
First Name:LEISHA
Middle Name:
Last Name:CALLAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:AR
Mailing Address - Zip Code:72933-9499
Mailing Address - Country:US
Mailing Address - Phone:479-965-5086
Mailing Address - Fax:877-694-8824
Practice Address - Street 1:1311 FORT ST
Practice Address - Street 2:SUITE L
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923-2045
Practice Address - Country:US
Practice Address - Phone:479-965-5086
Practice Address - Fax:877-694-8824
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR275225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S592OtherBLUE CROSS BLUE SHIELD
AR115954721Medicaid