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General NPI Number Information
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NPI Number | 1053613802
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Entity Type | Individual
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Provider Name | JUSTIN ORAN MCDIVITT OTD, R/L
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Gender | Male
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Dates
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Enumeration Date | 11/30/2010
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Last Update Date | 11/30/2010
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Provider Practice Location Address
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Address Line | 815 S WALNUT AVE
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City | COOKEVILLE
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State | TN
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Zip | 38501-5956
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Country | US
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Telephone | 931-646-7216
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Fax |
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Provider Business Mailing Address
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Address Line | 952 NOTTINGHAM DR
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City | COOKEVILLE
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State | TN
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Zip | 38506-4310
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 4071
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License Number State | TN
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