Provider Demographics
NPI:1891810016
Name:PROCTOR, SANDRA LEE (COTA)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LEE
Last Name:PROCTOR
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 1:6052 YEATON GLEN DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-3700
Mailing Address - Country:US
Mailing Address - Phone:336-327-7097
Mailing Address - Fax:
Practice Address - Street 1:1250 ARBOR RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-1106
Practice Address - Country:US
Practice Address - Phone:336-724-7921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4653224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant