Provider Demographics
NPI:1811025505
Name:STIVLAND, GREG (OTL)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:STIVLAND
Suffix:
Gender:M
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 UNIVERSITY DR STE 8
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2659
Mailing Address - Country:US
Mailing Address - Phone:919-493-7002
Mailing Address - Fax:919-403-1407
Practice Address - Street 1:3514 UNIVERSITY DR STE 8
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2659
Practice Address - Country:US
Practice Address - Phone:919-493-7002
Practice Address - Fax:919-403-1407
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1757225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7379398Medicaid
NC79398OtherBCBS OF NC