Healthcare Provider Details

I. General information

NPI: 1063544419
Provider Name (Legal Business Name): DIANE BAILEY GOLLOTT OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5778 NC HWY 88 WEST
WARRENSVILLE NC
28693-9209
US

IV. Provider business mailing address

330 LITTLE LAUREL RD
CRESTON NC
28615-8923
US

V. Phone/Fax

Practice location:
  • Phone: 336-384-4500
  • Fax:
Mailing address:
  • Phone: 336-385-2122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4499
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: