Provider Demographics
NPI:1366702557
Name:RAGAN, MARTY CLINTON (COTA/L)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:CLINTON
Last Name:RAGAN
Suffix:
Gender:M
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 1:2770 HAHN SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:NC
Mailing Address - Zip Code:28124-9358
Mailing Address - Country:US
Mailing Address - Phone:704-791-9891
Mailing Address - Fax:
Practice Address - Street 1:2770 HAHN SCOTT RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:NC
Practice Address - Zip Code:28124-9358
Practice Address - Country:US
Practice Address - Phone:704-791-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7917224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant