Provider Demographics
NPI:1053613802
Name:MCDIVITT, JUSTIN ORAN (OTD, R/L)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ORAN
Last Name:MCDIVITT
Suffix:
Gender:M
Credentials:OTD, R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-4310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 S WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-5956
Practice Address - Country:US
Practice Address - Phone:931-646-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist