Provider Demographics
NPI:1679625917
Name:REDDELL, TONI CONVILLE
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:CONVILLE
Last Name:REDDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 HIDDEN VALLEY LOOP
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6785
Mailing Address - Country:US
Mailing Address - Phone:501-850-8788
Mailing Address - Fax:
Practice Address - Street 1:5 REMINGTON DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-8202
Practice Address - Country:US
Practice Address - Phone:501-850-8788
Practice Address - Fax:501-850-8791
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1056225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U520OtherBCBS
AR143786721Medicaid