Provider Demographics
NPI:1861850067
Name:CHISHOLM, BRANDI MICHELLE (COTA/L, DOR)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:MICHELLE
Last Name:CHISHOLM
Suffix:
Gender:F
Credentials:COTA/L, DOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2231 COLUMBIA ROAD 78
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-8733
Mailing Address - Country:US
Mailing Address - Phone:870-904-7868
Mailing Address - Fax:870-234-7168
Practice Address - Street 1:2642 N DUDNEY RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-4305
Practice Address - Country:US
Practice Address - Phone:870-234-7000
Practice Address - Fax:870-234-7168
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A629224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant