Healthcare Provider Details

I. General information

NPI: 1598186843
Provider Name (Legal Business Name): SCOTILLIA NOEL FOGG OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 IRVING PKWY
HOLLY SPRINGS NC
27540-5300
US

IV. Provider business mailing address

PO BOX 142
WAKE FOREST NC
27588-0142
US

V. Phone/Fax

Practice location:
  • Phone: 919-793-3396
  • Fax:
Mailing address:
  • Phone: 919-793-3396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number115635
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8544
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number8544
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number8544
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: