Healthcare Provider Details

I. General information

NPI: 1912471202
Provider Name (Legal Business Name): SYDNEY WILKINSON BOYLES COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2019
Last Update Date: 01/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9129 MONROE RD STE 100-105
CHARLOTTE NC
28270-2429
US

IV. Provider business mailing address

9129 MONROE RD STE 100-105
CHARLOTTE NC
28270-2429
US

V. Phone/Fax

Practice location:
  • Phone: 704-847-2911
  • Fax: 704-847-2033
Mailing address:
  • Phone: 704-847-2911
  • Fax: 704-847-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number12274
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: