Provider Demographics
NPI:1760709539
Name:WAYNICK, UBOLWAN (COTA)
Entity Type:Individual
Prefix:
First Name:UBOLWAN
Middle Name:
Last Name:WAYNICK
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 1:817 BURTON TRL
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:TN
Mailing Address - Zip Code:37010-8938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5136
Practice Address - Country:US
Practice Address - Phone:931-552-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0936224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant