Provider Demographics
NPI:1750872172
Name:FIORE, JILLIAN ROSE (OTR)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ROSE
Last Name:FIORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:ROSE
Other - Last Name:NEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1229 TOTEROS DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6950
Mailing Address - Country:US
Mailing Address - Phone:508-737-9775
Mailing Address - Fax:
Practice Address - Street 1:1229 TOTEROS DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6950
Practice Address - Country:US
Practice Address - Phone:508-737-9775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5829225X00000X
NC11724225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH4207Medicaid