Provider Demographics
NPI:1184277469
Name:MARDIS, ANDREA LAUREN (COTA/L)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LAUREN
Last Name:MARDIS
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 1:6130 BREWSTER CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72940-9119
Mailing Address - Country:US
Mailing Address - Phone:479-739-8246
Mailing Address - Fax:
Practice Address - Street 1:2220 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3733
Practice Address - Country:US
Practice Address - Phone:479-434-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1504224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant