Basic Information
| Provider Information | |||||||||
| NPI: | 1801022611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALHOUN | ||||||||
| FirstName: | OCTAVIA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10100 FOREST HILLS RD | ||||||||
| Address2: | |||||||||
| City: | MACHESNEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611158234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157132738 | ||||||||
| FaxNumber: | 8152828597 | ||||||||
| Practice Location | |||||||||
| Address1: | 2931 ARBUSTO | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750540150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179042019 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2009 | ||||||||
| LastUpdateDate: | 02/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4064 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200117320A | 05 | OK | MEDICAID |