Basic Information
Provider Information | |||||||||
NPI: | 1205001393 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PADUA | ||||||||
FirstName: | JODY | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR/L, REHAB MANGER | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5935 MOUNT SINAI RD | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277058616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194022450 | ||||||||
FaxNumber: | 9194022452 | ||||||||
Practice Location | |||||||||
Address1: | 5935 MOUNT SINAI RD | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277058616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194022450 | ||||||||
FaxNumber: | 9194022452 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2008 | ||||||||
LastUpdateDate: | 08/22/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4602 | NC | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 4602 | 01 | NC | NORTH CAROLINA BOARD OF OCCUPATIONAL THERAPY | OTHER |