Provider Demographics
NPI:1700479417
Name:BOLOMOPE, GRACE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BOLOMOPE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1838
Mailing Address - Country:US
Mailing Address - Phone:301-645-2776
Mailing Address - Fax:847-730-0796
Practice Address - Street 1:70 VILLAGE ST
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1838
Practice Address - Country:US
Practice Address - Phone:307-222-4592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09214225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist