Provider Demographics
NPI:1417276361
Name:O'DELL, KRISTI DICKERSON (MA, CCC-CCC, SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:DICKERSON
Last Name:O'DELL
Suffix:
Gender:F
Credentials:MA, CCC-CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8313 WOODMILL DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-8161
Mailing Address - Country:US
Mailing Address - Phone:318-929-3886
Mailing Address - Fax:
Practice Address - Street 1:8313 WOODMILL DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-8161
Practice Address - Country:US
Practice Address - Phone:318-929-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist