Provider Demographics
NPI:1033667407
Name:BAUCOM, KORTNEY ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KORTNEY
Middle Name:ANN
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 CORRIHER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CHINA GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28023-8773
Mailing Address - Country:US
Mailing Address - Phone:704-433-1279
Mailing Address - Fax:
Practice Address - Street 1:955 CORRIHER SPRINGS RD
Practice Address - Street 2:
Practice Address - City:CHINA GROVE
Practice Address - State:NC
Practice Address - Zip Code:28023-8773
Practice Address - Country:US
Practice Address - Phone:704-433-1279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10421224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant