Provider Demographics
NPI:1518580190
Name:COLLETTE, MIKAYLIN SHAY (COTA/L)
Entity type:Individual
Prefix:
First Name:MIKAYLIN
Middle Name:SHAY
Last Name:COLLETTE
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 1:109 FAWN TRL
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:MO
Mailing Address - Zip Code:64865-8551
Mailing Address - Country:US
Mailing Address - Phone:417-389-6483
Mailing Address - Fax:
Practice Address - Street 1:910 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4565
Practice Address - Country:US
Practice Address - Phone:479-250-9838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1620224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant