Provider Demographics
NPI:1649609454
Name:PEROVICH, RENEE MARCIELE (COTA/L)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:MARCIELE
Last Name:PEROVICH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:MANUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:408 BRISTLECONE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-7697
Mailing Address - Country:US
Mailing Address - Phone:951-870-5501
Mailing Address - Fax:
Practice Address - Street 1:1700 PAMALEE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-2824
Practice Address - Country:US
Practice Address - Phone:910-488-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-02
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001688224Z00000X
NC9389224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant