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General NPI Number Information
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NPI Number | 1861696148
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Entity Type | Individual
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Provider Name | KATHLEEN C ODIN PTA
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Gender | Female
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Dates
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Enumeration Date | 06/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2727 N VICTORIA LAKERIDGE HC CENTER AEGIS THERAPIES
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City | ROSEVILLE
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State | MN
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Zip | 55113
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Country | US
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Telephone | 651-483-5431
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Fax |
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Provider Business Mailing Address
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Address Line | 8780 RAINIER ALCOVE
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City | WOODBURY
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State | MN
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Zip | 55125
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Country | US
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Telephone | 651-428-3902
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 250019
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License Number State | WI
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