Provider Demographics
NPI:1124684477
Name:HARRY, REGINALD LASALLE (COTA/L)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:LASALLE
Last Name:HARRY
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 1:205 WOODHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9289
Mailing Address - Country:US
Mailing Address - Phone:803-840-3808
Mailing Address - Fax:
Practice Address - Street 1:117 BELLFIELD RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:SC
Practice Address - Zip Code:29130-8261
Practice Address - Country:US
Practice Address - Phone:803-337-2257
Practice Address - Fax:803-337-2255
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2412224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant