Provider Demographics
NPI:1225155138
Name:BOBO, WANDA MARIE (COTAL)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:MARIE
Last Name:BOBO
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1227
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-1227
Mailing Address - Country:US
Mailing Address - Phone:864-587-8143
Mailing Address - Fax:
Practice Address - Street 1:233 TIFFANY PARK
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341
Practice Address - Country:US
Practice Address - Phone:864-902-5073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2625224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant