Provider Demographics
NPI:1245896125
Name:PRICE, OTHELLA M (LMT)
Entity type:Individual
Prefix:
First Name:OTHELLA
Middle Name:M
Last Name:PRICE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 HUNTER ST # B
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-5302
Mailing Address - Country:US
Mailing Address - Phone:252-267-5532
Mailing Address - Fax:
Practice Address - Street 1:606 HUNTER ST # B
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5302
Practice Address - Country:US
Practice Address - Phone:252-267-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019010014225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist