Healthcare Provider Details

I. General information

NPI: 1538142344
Provider Name (Legal Business Name): LAURA LEE O'DELL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA L KOLAKOWSKI

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 NW 4TH ST APT B
REDMOND OR
97756-1328
US

IV. Provider business mailing address

805 SW INDUSTRIAL WAY STE 3
BEND OR
97702-1093
US

V. Phone/Fax

Practice location:
  • Phone: 541-504-2350
  • Fax: 541-504-2354
Mailing address:
  • Phone: 541-585-2529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05114
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00009847
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: