Provider Demographics
NPI:1649480492
Name:MASHBURN-OLOMO, PHAEDRA YAMEAN (OTR/L)
Entity type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:YAMEAN
Last Name:MASHBURN-OLOMO
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 1:315 TILLMAN RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-6995
Mailing Address - Country:US
Mailing Address - Phone:347-749-2167
Mailing Address - Fax:
Practice Address - Street 1:315 TILLMAN RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32352-6995
Practice Address - Country:US
Practice Address - Phone:347-749-2167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016573225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty