Provider Demographics
NPI:1093831729
Name:RICHARDSON, OCTAVIA DESHAUN (LPTA)
Entity Type:Individual
Prefix:MS
First Name:OCTAVIA
Middle Name:DESHAUN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13204 GRIFFING AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-3080
Mailing Address - Country:US
Mailing Address - Phone:216-921-0981
Mailing Address - Fax:
Practice Address - Street 1:20265 EMERY RD
Practice Address - Street 2:
Practice Address - City:NORTH RANDALL
Practice Address - State:OH
Practice Address - Zip Code:44128-4122
Practice Address - Country:US
Practice Address - Phone:216-584-2720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06426225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant