Provider Demographics
NPI:1891481313
Name:FULLER, MARY D (COTA/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:FULLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:680 FAIRVIEW FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NC
Mailing Address - Zip Code:28730-9647
Mailing Address - Country:US
Mailing Address - Phone:828-772-9631
Mailing Address - Fax:
Practice Address - Street 1:611 OLD US HWY 70 E
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-9488
Practice Address - Country:US
Practice Address - Phone:828-669-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13714224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant