Provider Demographics
NPI:1467209601
Name:NEWSOME, JUSTICE DIVINE (COTA/L)
Entity type:Individual
Prefix:
First Name:JUSTICE
Middle Name:DIVINE
Last Name:NEWSOME
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 1:1317 LEGACY FALLS DR APT 207
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1794
Mailing Address - Country:US
Mailing Address - Phone:910-391-4989
Mailing Address - Fax:
Practice Address - Street 1:1317 LEGACY FALLS DR APT 207
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-1794
Practice Address - Country:US
Practice Address - Phone:910-391-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant