Provider Demographics
NPI:1639690977
Name:BLACK, ALLIE RAY (COTA)
Entity type:Individual
Prefix:
First Name:ALLIE
Middle Name:RAY
Last Name:BLACK
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 1:416 PULLMAN RD
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-9221
Mailing Address - Country:US
Mailing Address - Phone:870-784-3353
Mailing Address - Fax:
Practice Address - Street 1:416 PULLMAN RD
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-9221
Practice Address - Country:US
Practice Address - Phone:870-784-3353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1220224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant