Provider Demographics
NPI:1437463635
Name:ODETTE, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:ODETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 IH 35 N STE Q
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4204
Mailing Address - Country:US
Mailing Address - Phone:512-310-7665
Mailing Address - Fax:512-310-9228
Practice Address - Street 1:1208 IH 35 N STE Q
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4204
Practice Address - Country:US
Practice Address - Phone:512-310-7665
Practice Address - Fax:512-310-9228
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2065520225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0944746-02Medicaid
74-2745294OtherTAX ID
0031DGOtherBLUE CROSS BLUE SHIELD
TX0944746-02Medicaid