Provider Demographics
NPI:1497554232
Name:THEODORE, IZADORA THAMIE
Entity type:Individual
Prefix:
First Name:IZADORA
Middle Name:THAMIE
Last Name:THEODORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-3814
Mailing Address - Country:US
Mailing Address - Phone:401-422-9717
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4177
Practice Address - Country:US
Practice Address - Phone:781-885-0277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator