Healthcare Provider Details

I. General information

NPI: 1003739053
Provider Name (Legal Business Name): AVERY SMITH COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 GILLESPIE ST
FAYETTEVILLE NC
28306-3053
US

IV. Provider business mailing address

129 GARNER RD APT 3A
SPARTANBURG SC
29303-3290
US

V. Phone/Fax

Practice location:
  • Phone: 910-678-2300
  • Fax:
Mailing address:
  • Phone: 866-871-8519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number17754
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: