Provider Demographics
NPI:1275745630
Name:IMMEL, LAGENA KAY (OTR)
Entity Type:Individual
Prefix:MS
First Name:LAGENA
Middle Name:KAY
Last Name:IMMEL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1622
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-1622
Mailing Address - Country:US
Mailing Address - Phone:479-754-2107
Mailing Address - Fax:
Practice Address - Street 1:1000 W BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-2252
Practice Address - Country:US
Practice Address - Phone:479-754-6210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1512225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics