Provider Demographics
NPI:1710280086
Name:WEATHERMAN, MICHAEL SHANE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:WEATHERMAN
Suffix:
Gender:M
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 1:4124 PROVIDENCE RD APT B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4479
Mailing Address - Country:US
Mailing Address - Phone:828-707-7627
Mailing Address - Fax:
Practice Address - Street 1:4124 PROVIDENCE RD APT B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4479
Practice Address - Country:US
Practice Address - Phone:828-707-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2880224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant