Provider Demographics
NPI:1578908109
Name:ODUM, TIFFANY SHANAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SHANAE
Last Name:ODUM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 GILDA CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-6528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3529225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist