Provider Demographics
NPI:1952858607
Name:SMITH, AMANDA NOELLE (OT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NOELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 CANAL AVE E
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-3003
Mailing Address - Country:US
Mailing Address - Phone:870-238-2233
Mailing Address - Fax:870-208-8255
Practice Address - Street 1:615 CANAL AVE E
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3003
Practice Address - Country:US
Practice Address - Phone:870-238-2233
Practice Address - Fax:870-208-8255
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2948225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist