Provider Demographics
NPI:1598186843
Name:FOGG, SCOTILLIA NOEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:SCOTILLIA
Middle Name:NOEL
Last Name:FOGG
Suffix:
Gender:F
Credentials:OTR/L
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 142
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-0142
Mailing Address - Country:US
Mailing Address - Phone:919-793-3396
Mailing Address - Fax:
Practice Address - Street 1:401 IRVING PKWY
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-5300
Practice Address - Country:US
Practice Address - Phone:919-793-3396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115635225X00000X
NC8544225X00000X, 225XP0019X, 225XN1300X
225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ49100E346OtherMEDICARE PTAN
NC46-3989097OtherEIN