Provider Demographics
NPI:1689750689
Name:FAHEY, MANDI J (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MANDI
Middle Name:J
Last Name:FAHEY
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 INGLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758
Mailing Address - Country:US
Mailing Address - Phone:630-770-9510
Mailing Address - Fax:479-289-5129
Practice Address - Street 1:4905 S INGLEWOOD RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-9011
Practice Address - Country:US
Practice Address - Phone:630-770-9510
Practice Address - Fax:479-289-5129
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006980225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AROTR2510OtherARKANSAS STATE MED BOARD