Provider Demographics
NPI:1114044948
Name:ODEAN, HOLLY J (AT,C)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:J
Last Name:ODEAN
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4253 PRESCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:IL
Mailing Address - Zip Code:60534-1530
Mailing Address - Country:US
Mailing Address - Phone:708-447-4599
Mailing Address - Fax:
Practice Address - Street 1:1 ERIE CT STE 7120
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2510
Practice Address - Country:US
Practice Address - Phone:708-848-4662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL960007962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer