Provider Demographics
NPI:1134471774
Name:APODACA, RANDY LEE (PHD, OT/L)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LEE
Last Name:APODACA
Suffix:
Gender:M
Credentials:PHD, OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:AK
Mailing Address - Zip Code:99574-0421
Mailing Address - Country:US
Mailing Address - Phone:907-978-4223
Mailing Address - Fax:
Practice Address - Street 1:602 CHASE AVE.
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:AK
Practice Address - Zip Code:99574
Practice Address - Country:US
Practice Address - Phone:907-424-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2198225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics