Provider Demographics
NPI:1376924282
Name:OBODO, LAWRETTA
Entity Type:Individual
Prefix:
First Name:LAWRETTA
Middle Name:
Last Name:OBODO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 NEW ORCHARD PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2288
Mailing Address - Country:US
Mailing Address - Phone:240-472-8434
Mailing Address - Fax:
Practice Address - Street 1:7520 SURRATTS RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3353
Practice Address - Country:US
Practice Address - Phone:301-856-1660
Practice Address - Fax:301-785-2076
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3763225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant