Healthcare Provider Details

I. General information

NPI: 1104337062
Provider Name (Legal Business Name): DEMETRAS CHUNTA' MIDDLETON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 WILLOW TREE CIR
CORDOVA TN
38018-6376
US

IV. Provider business mailing address

4064 BORDEAUX CREEK CV S
MEMPHIS TN
38125-2668
US

V. Phone/Fax

Practice location:
  • Phone: 901-794-7988
  • Fax:
Mailing address:
  • Phone: 901-428-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4400
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5535
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: