Provider Demographics
NPI:1548650252
Name:MATHIS, OCTAVIA KARRA (ATC)
Entity type:Individual
Prefix:MISS
First Name:OCTAVIA
Middle Name:KARRA
Last Name:MATHIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 CHATHAM HALL DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5428
Mailing Address - Country:US
Mailing Address - Phone:757-404-1810
Mailing Address - Fax:
Practice Address - Street 1:192 YELLOWSTONE DR
Practice Address - Street 2:APT 308
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-8120
Practice Address - Country:US
Practice Address - Phone:757-404-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260022052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer