1083012926 NPI number — GRETCHEN RUTH CORRELL OT

Table of content: GRETCHEN RUTH CORRELL OT (NPI 1083012926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083012926 NPI number — GRETCHEN RUTH CORRELL OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORRELL
Provider First Name:
GRETCHEN
Provider Middle Name:
RUTH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083012926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 WILLIAM PENN PLZ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27704-2150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-220-5255
Provider Business Mailing Address Fax Number:
919-313-1276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 DURALEIGH RD
Provider Second Line Business Practice Location Address:
SUITE
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27612-8106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-788-8797
Provider Business Practice Location Address Fax Number:
919-788-8798
Provider Enumeration Date:
12/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , with the licence number:  4642 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4642 . This is a "NORTH CAROLINA OCCUPATIONAL THERAPY LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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