Basic Information
| Provider Information | |||||||||
| NPI: | 1649609454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEROVICH | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | MARCIELE | ||||||||
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| Credential: | COTA/L | ||||||||
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| OtherLastName: | MANUS | ||||||||
| OtherFirstName: | RENEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 408 BRISTLECONE RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283117697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518705501 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 PAMALEE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283012824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882295 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2013 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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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 | 224Z00000X | OTA001688 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 9389 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.