Provider Demographics
NPI:1932676798
Name:BEARDEN, STACEY NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:NICOLE
Last Name:BEARDEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 S S ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3446
Mailing Address - Country:US
Mailing Address - Phone:479-650-5030
Mailing Address - Fax:
Practice Address - Street 1:913 N 24TH ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-3743
Practice Address - Country:US
Practice Address - Phone:479-650-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1199224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant