Healthcare Provider Details

I. General information

NPI: 1639371040
Provider Name (Legal Business Name): DENISE H MOTT OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1071 MORRISON DR STE A
CHARLESTON SC
29403
US

IV. Provider business mailing address

3921 NELSONVIEW DR
AWENDAW SC
29429-6086
US

V. Phone/Fax

Practice location:
  • Phone: 843-723-6915
  • Fax:
Mailing address:
  • Phone: 843-884-8955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number294
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: