Healthcare Provider Details

I. General information

NPI: 1861668378
Provider Name (Legal Business Name): TERESA RODDY OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S SUMMIT ST UNIT F
CRESCENT CITY FL
32112-3047
US

IV. Provider business mailing address

405 S SUMMIT ST UNIT F
CRESCENT CITY FL
32112-3047
US

V. Phone/Fax

Practice location:
  • Phone: 386-698-4720
  • Fax: 386-698-4866
Mailing address:
  • Phone: 386-698-4720
  • Fax: 386-698-4866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT13097
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: