Provider Demographics
NPI:1194399634
Name:COULBOURNE, HILLARY (COTA)
Entity Type:Individual
Prefix:
First Name:HILLARY
Middle Name:
Last Name:COULBOURNE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 MILLDAM PASS
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-8250
Mailing Address - Country:US
Mailing Address - Phone:410-310-1756
Mailing Address - Fax:
Practice Address - Street 1:580 ROBERT DANIEL DR
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-7448
Practice Address - Country:US
Practice Address - Phone:843-765-2804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5114224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant