Provider Demographics
NPI:1336731033
Name:HATHCOCK, ANDREA NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:HATHCOCK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 FAITH CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3315 FAITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9300
Practice Address - Country:US
Practice Address - Phone:704-882-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11134224ZL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantLow Vision