Healthcare Provider Details

I. General information

NPI: 1083898399
Provider Name (Legal Business Name): OCCUPATIONAL THERAPY SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3022 CHISHOLM CT
WAXHAW NC
28173-7865
US

IV. Provider business mailing address

3022 CHISHOLM CT
WAXHAW NC
28173-7865
US

V. Phone/Fax

Practice location:
  • Phone: 704-843-2020
  • Fax:
Mailing address:
  • Phone: 704-843-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LAUREN JENNIFER MULLAN
Title or Position: OWNER
Credential: M.A., OTR/L, ITFS-P
Phone: 704-843-2020