Provider Demographics
NPI:1194869180
Name:ODUM, THERESA BRYANT (OCCUPATIONAL THERAPY)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:BRYANT
Last Name:ODUM
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W MAIN ST
Mailing Address - Street 2:STE 460
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1447
Mailing Address - Country:US
Mailing Address - Phone:334-794-0591
Mailing Address - Fax:334-793-6073
Practice Address - Street 1:1000 W MAIN ST
Practice Address - Street 2:STE 460
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1447
Practice Address - Country:US
Practice Address - Phone:334-794-0591
Practice Address - Fax:334-793-6073
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1269225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-32382OtherBCBS