Healthcare Provider Details

I. General information

NPI: 1629588736
Provider Name (Legal Business Name): GAYLE S BREZICKI COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 ROBINWOOD RD
GASTONIA NC
28054-1693
US

IV. Provider business mailing address

162 KNOXVIEW LN
MOORESVILLE NC
28117-9602
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-2319
  • Fax:
Mailing address:
  • Phone: 704-778-6364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number11148
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: