Provider Demographics
NPI:1528732179
Name:LEVERITT, LAUREL (COTA/L)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:LEVERITT
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 1:90 BLACKGUM ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-4514
Mailing Address - Country:US
Mailing Address - Phone:479-287-1839
Mailing Address - Fax:
Practice Address - Street 1:1320 MAUL RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-2618
Practice Address - Country:US
Practice Address - Phone:870-836-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1747224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR275832721Medicaid
452386OtherNBCOT