Healthcare Provider Details

I. General information

NPI: 1245566686
Provider Name (Legal Business Name): SUMMER BENTLEY BLACKBURN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S GENERALS BLVD
LINCOLNTON NC
28092
US

IV. Provider business mailing address

1845 JETTON DR
VALE NC
28168-7611
US

V. Phone/Fax

Practice location:
  • Phone: 704-735-8065
  • Fax:
Mailing address:
  • Phone: 828-302-6460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4622
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: