Healthcare Provider Details

I. General information

NPI: 1881472983
Provider Name (Legal Business Name): ALWAJUDAT LAWAL OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 DIAMOND DR
NORTH DINWIDDIE VA
23803-7495
US

IV. Provider business mailing address

2111 WAKEFIELD AVE
COLONIAL HEIGHTS VA
23834-2521
US

V. Phone/Fax

Practice location:
  • Phone: 804-518-0780
  • Fax:
Mailing address:
  • Phone: 312-956-5651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119009331
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: