Provider Demographics
NPI:1104307875
Name:ICKES, SARAH LAUREN (COTA/L)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:LAUREN
Last Name:ICKES
Suffix:
Gender:F
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 1:2104 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-4565
Mailing Address - Country:US
Mailing Address - Phone:813-454-5166
Mailing Address - Fax:
Practice Address - Street 1:2680 S MEBANE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5695
Practice Address - Country:US
Practice Address - Phone:336-397-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10107224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant