Provider Demographics
NPI:1063544419
Name:GOLLOTT, DIANE BAILEY (OTR)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:BAILEY
Last Name:GOLLOTT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 LITTLE LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:NC
Mailing Address - Zip Code:28615-8923
Mailing Address - Country:US
Mailing Address - Phone:336-385-2122
Mailing Address - Fax:
Practice Address - Street 1:5778 NC HWY 88 WEST
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28693-9209
Practice Address - Country:US
Practice Address - Phone:336-384-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4499225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301630Medicaid