Provider Demographics
NPI:1831796994
Name:ELLIOTT, MATTIE DEVIN (COTA/L)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:DEVIN
Last Name:ELLIOTT
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 1:1531 GATOR TRAK
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-9146
Mailing Address - Country:US
Mailing Address - Phone:843-621-5210
Mailing Address - Fax:
Practice Address - Street 1:1801 OLD TROLLEY RD STE 203
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8283
Practice Address - Country:US
Practice Address - Phone:843-594-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5164224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant