Provider Demographics
NPI:1669623492
Name:WALLS, CARROLL EUGENE JR (OTR/L)
Entity type:Individual
Prefix:MR
First Name:CARROLL
Middle Name:EUGENE
Last Name:WALLS
Suffix:JR
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10712 YOSEMITE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-3659
Mailing Address - Country:US
Mailing Address - Phone:501-681-4448
Mailing Address - Fax:
Practice Address - Street 1:1600 RIVERFRONT DRIVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3121
Practice Address - Country:US
Practice Address - Phone:501-663-6965
Practice Address - Fax:501-603-0675
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR592225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134290721Medicaid