Healthcare Provider Details

I. General information

NPI: 1356781918
Provider Name (Legal Business Name): MS. SUSAN G ODELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 20TH ST
HUNTINGTON WV
25703-2021
US

IV. Provider business mailing address

1119 20TH ST
HUNTINGTON WV
25703-2021
US

V. Phone/Fax

Practice location:
  • Phone: 304-522-7553
  • Fax: 304-522-7883
Mailing address:
  • Phone: 304-522-7553
  • Fax: 304-522-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberKY-2114
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: