Healthcare Provider Details

I. General information

NPI: 1679915037
Provider Name (Legal Business Name): ROBYN CREDLE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 US HIGHWAY 17 S
HOLLY RIDGE NC
28445-8660
US

IV. Provider business mailing address

624 US HIGHWAY 17 S
HOLLY RIDGE NC
28445-8660
US

V. Phone/Fax

Practice location:
  • Phone: 910-329-4444
  • Fax:
Mailing address:
  • Phone: 910-329-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2102
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: