Provider Demographics
NPI:1699945519
Name:PARDUE, GWYNN (COTA)
Entity type:Individual
Prefix:MS
First Name:GWYNN
Middle Name:
Last Name:PARDUE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 GRALYN DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27020-8277
Mailing Address - Country:US
Mailing Address - Phone:336-468-1904
Mailing Address - Fax:
Practice Address - Street 1:903 W MAIN ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-7807
Practice Address - Country:US
Practice Address - Phone:336-679-8863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4592224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant