Provider Demographics
NPI:1477031367
Name:COOKINHAM, THEODORE DALTON (OTA)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:DALTON
Last Name:COOKINHAM
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 W OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS FRESNOS
Mailing Address - State:TX
Mailing Address - Zip Code:78566-3635
Mailing Address - Country:US
Mailing Address - Phone:956-233-4111
Mailing Address - Fax:
Practice Address - Street 1:503 W OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:LOS FRESNOS
Practice Address - State:TX
Practice Address - Zip Code:78566-3635
Practice Address - Country:US
Practice Address - Phone:956-233-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210099224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant