Healthcare Provider Details

I. General information

NPI: 1528202561
Provider Name (Legal Business Name): HEIDI DEBORAH O'DELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 11/15/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 W HILLCREST RD
SANFORD MI
48657-9707
US

IV. Provider business mailing address

1565 W HILLCREST RD
SANFORD MI
48657-9707
US

V. Phone/Fax

Practice location:
  • Phone: 989-495-3819
  • Fax:
Mailing address:
  • Phone: 989-495-3819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004094
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: