Provider Demographics
NPI:1386109643
Name:BENNETT, LORRAINE SULLIVAN (COTA/L)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:SULLIVAN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:LORRAINE
Other - Middle Name:S
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:2129 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:SC
Mailing Address - Zip Code:29541-3630
Mailing Address - Country:US
Mailing Address - Phone:843-618-0698
Mailing Address - Fax:
Practice Address - Street 1:HANNA PAMPLICO ELEMENTARY SCHOOL
Practice Address - Street 2:2131 SOUTH PAMPLICO HIGHWAY
Practice Address - City:PAMPLICO
Practice Address - State:SC
Practice Address - Zip Code:29583
Practice Address - Country:US
Practice Address - Phone:843-493-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1319224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty