Provider Demographics
NPI:1780036988
Name:PRIME OCCUPATIONAL THERAPY PLLC
Entity Type:Organization
Organization Name:PRIME OCCUPATIONAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAHTSENTE
Authorized Official - Middle Name:WORKU
Authorized Official - Last Name:EBRON
Authorized Official - Suffix:
Authorized Official - Credentials:MSHS OTR/L
Authorized Official - Phone:919-539-8661
Mailing Address - Street 1:1004 PEONY CT
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7051
Mailing Address - Country:US
Mailing Address - Phone:919-539-8661
Mailing Address - Fax:919-373-9564
Practice Address - Street 1:1004 PEONY CT
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7051
Practice Address - Country:US
Practice Address - Phone:919-539-8661
Practice Address - Fax:919-373-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4262320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities