Provider Demographics
NPI:1760639413
Name:WYSE, KEALEY LOY (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KEALEY
Middle Name:LOY
Last Name:WYSE
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 1:8724 BUCK RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-9506
Mailing Address - Country:US
Mailing Address - Phone:501-860-5775
Mailing Address - Fax:
Practice Address - Street 1:6520 BASELINE RD
Practice Address - Street 2:SUITE A
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4732
Practice Address - Country:US
Practice Address - Phone:501-570-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARO-T0842224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant