Provider Demographics
NPI:1124129952
Name:SOUTHECORVO, ROBIN A (OTRL)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:A
Last Name:SOUTHECORVO
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2493
Mailing Address - Country:US
Mailing Address - Phone:828-253-7521
Mailing Address - Fax:828-251-5992
Practice Address - Street 1:18 MEDICAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2493
Practice Address - Country:US
Practice Address - Phone:828-253-7521
Practice Address - Fax:828-251-5992
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
NC0620225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7302006Medicaid
NC7302006Medicaid