Provider Demographics
NPI:1710284682
Name:OKODUWA, TRACEE S (OT)
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:S
Last Name:OKODUWA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1478
Mailing Address - Country:US
Mailing Address - Phone:704-824-4999
Mailing Address - Fax:
Practice Address - Street 1:2675 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1478
Practice Address - Country:US
Practice Address - Phone:704-824-4999
Practice Address - Fax:704-824-3999
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3131225X00000X
NC6082225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist