Provider Demographics
NPI:1104236744
Name:ODAKURA, CLAIRE EDEN (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:CLAIRE
Middle Name:EDEN
Last Name:ODAKURA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:CLAIRE
Other - Middle Name:EDEN
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2089 TERON TRCE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2089 TERON TRCE
Practice Address - Street 2:SUITE 120
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1609
Practice Address - Country:US
Practice Address - Phone:770-904-6009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005810225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003147296CMedicaid