Provider Demographics
NPI:1861699175
Name:NIEBERGALL, JUDITH (COTA MLDT)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:
Last Name:NIEBERGALL
Suffix:
Gender:F
Credentials:COTA MLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 BRUNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5528
Mailing Address - Country:US
Mailing Address - Phone:843-777-2196
Mailing Address - Fax:843-777-2051
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-777-2196
Practice Address - Fax:843-777-2051
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC479224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant