Provider Demographics
NPI:1821241415
Name:MCCOY, AUONTWANNQUE B R (COTA/L)
Entity Type:Individual
Prefix:
First Name:AUONTWANNQUE
Middle Name:B R
Last Name:MCCOY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:AUONTWANNQUE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:3681 LEAPHART RD STE A
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3068
Mailing Address - Country:US
Mailing Address - Phone:803-454-6090
Mailing Address - Fax:803-451-6105
Practice Address - Street 1:3881-A LEAPHART RD.
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-454-6090
Practice Address - Fax:803-451-6105
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2490224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant