Provider Demographics
NPI:1780467167
Name:REAVES, ABAGAIL GRACE (OTA)
Entity type:Individual
Prefix:
First Name:ABAGAIL
Middle Name:GRACE
Last Name:REAVES
Suffix:
Gender:F
Credentials:OTA
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 1095
Mailing Address - Street 2:
Mailing Address - City:WEST FORK
Mailing Address - State:AR
Mailing Address - Zip Code:72774-1095
Mailing Address - Country:US
Mailing Address - Phone:815-922-1597
Mailing Address - Fax:
Practice Address - Street 1:121 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST FORK
Practice Address - State:AR
Practice Address - Zip Code:72774-3119
Practice Address - Country:US
Practice Address - Phone:815-922-1597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1959224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant