Healthcare Provider Details

I. General information

NPI: 1710284682
Provider Name (Legal Business Name): TRACEE S OKODUWA OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 COURT DR
GASTONIA NC
28054-1478
US

IV. Provider business mailing address

2675 COURT DR
GASTONIA NC
28054-1478
US

V. Phone/Fax

Practice location:
  • Phone: 704-824-4999
  • Fax: 704-824-3999
Mailing address:
  • Phone: 704-824-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3131
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6082
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: