Provider Demographics
NPI:1245254564
Name:CHEATHAM, CHRISTY L (OT)
Entity type:Individual
Prefix:MS
First Name:CHRISTY
Middle Name:L
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:CHRISTY
Other - Middle Name:L
Other - Last Name:CHEATHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:1515 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-3801
Mailing Address - Country:US
Mailing Address - Phone:870-234-2255
Mailing Address - Fax:870-234-2274
Practice Address - Street 1:1515 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3801
Practice Address - Country:US
Practice Address - Phone:870-234-2255
Practice Address - Fax:870-234-2274
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1343225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162928721Medicaid
AR162928721Medicaid