Provider Demographics
NPI:1649872813
Name:ACHTERBERG, JOHN JEFFERY (COTA/L)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JEFFERY
Last Name:ACHTERBERG
Suffix:
Gender:M
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 1:1530 MASON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:STOKES
Mailing Address - State:NC
Mailing Address - Zip Code:27884-9797
Mailing Address - Country:US
Mailing Address - Phone:919-207-7627
Mailing Address - Fax:
Practice Address - Street 1:290 KEEL RD
Practice Address - Street 2:
Practice Address - City:GRANTSBORO
Practice Address - State:NC
Practice Address - Zip Code:28529-9424
Practice Address - Country:US
Practice Address - Phone:252-745-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12342224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant