Provider Demographics
NPI:1619121894
Name:COLLISTER, LAURIE (COTA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:COLLISTER
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 1:506 GALESBURG DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-7331
Mailing Address - Country:US
Mailing Address - Phone:704-776-4932
Mailing Address - Fax:
Practice Address - Street 1:4390 BELLE OAKS DR
Practice Address - Street 2:SUITE 120
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8559
Practice Address - Country:US
Practice Address - Phone:843-571-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2409224Z00000X
NC4507224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant