Healthcare Provider Details

I. General information

NPI: 1578052171
Provider Name (Legal Business Name): MARY ANNE E ODANIEL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANNE E JOHNSON PT

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 S MAIN ST
MADISONVILLE KY
42431
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-825-0069
  • Fax: 270-824-9777
Mailing address:
  • Phone: 270-688-1330
  • Fax: 270-688-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007430
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberTP2018037
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: