Provider Demographics
NPI:1245566686
Name:BLACKBURN, SUMMER BENTLEY (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:SUMMER
Middle Name:BENTLEY
Last Name:BLACKBURN
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 1:1845 JETTON DR
Mailing Address - Street 2:
Mailing Address - City:VALE
Mailing Address - State:NC
Mailing Address - Zip Code:28168-7611
Mailing Address - Country:US
Mailing Address - Phone:828-302-6460
Mailing Address - Fax:
Practice Address - Street 1:515 S GENERALS BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092
Practice Address - Country:US
Practice Address - Phone:704-735-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4622224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant