MEDICARE: MRS. LAURA SHALEA WOOLDRIDGE OTR/ ATP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	109985	TX

General Provider Information

NPI Number	:	1457602096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA SHALEA WOOLDRIDGE OTR/ ATP

Provider Business Mailing Address
First Line	:	701 N EDGEFIELD AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-3616
Country	:	US
Telephone Number	:	972-814-6665
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 N EDGEFIELD AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-3616
Country	:	US
Telephone Number	:	972-814-6665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2012
Last Update Date	:	09/23/2012

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