Provider Demographics
NPI:1871559534
Name:COLBERT, JAMES COREY (OTR/L)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:COREY
Last Name:COLBERT
Suffix:
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:PO BOX 1398
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-1398
Mailing Address - Country:US
Mailing Address - Phone:479-770-5655
Mailing Address - Fax:479-770-5656
Practice Address - Street 1:2525 S MARKET ST
Practice Address - Street 2:STE 100
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8163
Practice Address - Country:US
Practice Address - Phone:479-770-5655
Practice Address - Fax:479-770-5656
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1941225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y103OtherBLUE CROSS BLUE SHEILD
AR155213721Medicaid