Provider Demographics
NPI:1801022611
Name:CALHOUN, OCTAVIA R (PT)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:R
Last Name:CALHOUN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 FOREST HILLS RD
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-8234
Mailing Address - Country:US
Mailing Address - Phone:815-713-2738
Mailing Address - Fax:815-282-8597
Practice Address - Street 1:2931 ARBUSTO
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-0150
Practice Address - Country:US
Practice Address - Phone:817-904-2019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200117320AMedicaid
OK9000522529Medicare PIN