Healthcare Provider Details

I. General information

NPI: 1104060730
Provider Name (Legal Business Name): CHRISTY LYNN MCCLURE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 COALITION DR
MYRTLE BEACH SC
29588-6183
US

IV. Provider business mailing address

3650 COALITION DR
MYRTLE BEACH SC
29588-6183
US

V. Phone/Fax

Practice location:
  • Phone: 843-293-7713
  • Fax: 843-293-1855
Mailing address:
  • Phone: 843-293-7713
  • Fax: 843-293-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1187
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: