MEDICARE: STACEY HICKS NESBITT COTA/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	224Z00000X	Occupational Therapy Assistant		SC

General Provider Information

NPI Number	:	1982276374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY HICKS NESBITT COTA/L

Provider Business Mailing Address
First Line	:	6507 QUEENS WAY DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-1530
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6507 QUEENS WAY DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-1530
Country	:	US
Telephone Number	:	803-360-3225
Fax Number	:

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

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	07/14/2021

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