Provider Demographics
NPI:1962635888
Name:BURLESON, TRACI MICHELLE (COTA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MICHELLE
Last Name:BURLESON
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 1:1845 N ALBANY LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-5380
Mailing Address - Country:US
Mailing Address - Phone:704-995-0068
Mailing Address - Fax:
Practice Address - Street 1:519 LATHAM DR
Practice Address - Street 2:SCHMIEDING KIDS FIRST
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-8360
Practice Address - Country:US
Practice Address - Phone:479-750-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A574224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant