Provider Demographics
NPI:1699035642
Name:BAGWELL, CANDICE ROSE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:ROSE
Last Name:BAGWELL
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 1:315 E QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:SC
Mailing Address - Zip Code:29670-1721
Mailing Address - Country:US
Mailing Address - Phone:864-403-2000
Mailing Address - Fax:
Practice Address - Street 1:315 E QUEEN ST
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:SC
Practice Address - Zip Code:29670-1721
Practice Address - Country:US
Practice Address - Phone:864-403-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3007224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant