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General NPI Number Information
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NPI Number | 1104307875
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Entity Type | Individual
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Provider Name | SARAH LAUREN ICKES COTA/L
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Gender | Female
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Dates
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Enumeration Date | 08/22/2018
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Last Update Date | 08/22/2018
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Provider Practice Location Address
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Address Line | 2680 S MEBANE ST
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City | BURLINGTON
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State | NC
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Zip | 27215-5695
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Country | US
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Telephone | 336-397-4595
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Fax |
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Provider Business Mailing Address
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Address Line | 2104 WOODLAND AVE
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City | BURLINGTON
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State | NC
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Zip | 27215-4565
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Country | US
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Telephone | 813-454-5166
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 10107
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License Number State | NC
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