Healthcare Provider Details

I. General information

NPI: 1104236744
Provider Name (Legal Business Name): CLAIRE EDEN ODAKURA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CLAIRE EDEN STONE OTR/L

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2089 TERON TRCE SUITE 120
DACULA GA
30019-1609
US

IV. Provider business mailing address

2089 TERON TRCE SUITE 120
DACULA GA
30019-1609
US

V. Phone/Fax

Practice location:
  • Phone: 770-904-6009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT005810
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT005810
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: