Provider Demographics
NPI:1053923896
Name:DICESARE, MAGGIE MARIE (COTA/L)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:MARIE
Last Name:DICESARE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6193 NC HIGHWAY 102 W
Mailing Address - Street 2:
Mailing Address - City:CHOCOWINITY
Mailing Address - State:NC
Mailing Address - Zip Code:27817-9108
Mailing Address - Country:US
Mailing Address - Phone:252-531-5190
Mailing Address - Fax:
Practice Address - Street 1:4801 EDWARDS MILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4417
Practice Address - Country:US
Practice Address - Phone:919-787-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12401224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant