Healthcare Provider Details

I. General information

NPI: 1205071115
Provider Name (Legal Business Name): MARY JANE DOWLING COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4390 BELLE OAKS DR SUITE 120
NORTH CHARLESTON SC
29405-8559
US

IV. Provider business mailing address

2503 BEAR STAND TRL
MYRTLE BEACH SC
29588-8442
US

V. Phone/Fax

Practice location:
  • Phone: 843-571-2700
  • Fax:
Mailing address:
  • Phone: 843-602-1793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2372
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: