Healthcare Provider Details

I. General information

NPI: 1447376090
Provider Name (Legal Business Name): SUZANNE BYNUM OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 CARMEL EXECUTIVE PARK DR SUITE 310
CHARLOTTE NC
28226-8251
US

IV. Provider business mailing address

7402 SUN DANCE DR.
FORT MILL SC
29715
US

V. Phone/Fax

Practice location:
  • Phone: 704-752-1616
  • Fax: 704-759-0799
Mailing address:
  • Phone: 803-802-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number4194
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: