Provider Demographics
NPI:1447656806
Name:BURTON, WANDA CHESTNUT (LICENSED COTA)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:CHESTNUT
Last Name:BURTON
Suffix:
Gender:F
Credentials:LICENSED COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2815
Mailing Address - Country:US
Mailing Address - Phone:919-424-5086
Mailing Address - Fax:
Practice Address - Street 1:205 EMERALD POND LN
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-6051
Practice Address - Country:US
Practice Address - Phone:919-493-4713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7393224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant