Basic Information
| Provider Information | |||||||||
| NPI: | 1538618301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGOSTINE | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 HUNT CLUB LN | ||||||||
| Address2: | APT H | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276061893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033646350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 113 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273304020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197770240 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2016 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.