MEDICARE: CONSTANCE WAKEFORD OT/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	543	NC

General Provider Information

NPI Number	:	1821462961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONSTANCE WAKEFORD OT/L

Provider Business Mailing Address
First Line	:	321 S COLUMBIA ST
Second Line	:	BONDURANT HALL SUITE 2050
City	:	CHAPEL HILL
State	:	NC
Zip	:	27599-7122
Country	:	US
Telephone Number	:	919-843-4464
Fax Number	:	919-966-9007

Provider Business Practice Location Address
First Line	:	321 S COLUMBIA ST
Second Line	:	BONDURANT HALL SUITE 2050
City	:	CHAPEL HILL
State	:	NC
Zip	:	27599-7122
Country	:	US
Telephone Number	:	919-843-4464
Fax Number	:	919-966-9007

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2015
Last Update Date	:	11/29/2015

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