Provider Demographics
NPI:1679037162
Name:PADDOCK, THERESA LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:PADDOCK
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 1:5220 13TH AVENUE DR W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4235
Mailing Address - Country:US
Mailing Address - Phone:248-420-7186
Mailing Address - Fax:
Practice Address - Street 1:8254 118TH AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19107225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1020264OtherNATIONAL BOARD CERTIFICATION
OK2015OtherLICENSURE
MI5201004033OtherLICENSURE