Provider Demographics
NPI:1538142344
Name:O'DELL, LAURA LEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LEE
Last Name:O'DELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:KOLAKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:805 SW INDUSTRIAL WAY STE 3
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1093
Mailing Address - Country:US
Mailing Address - Phone:541-585-2529
Mailing Address - Fax:
Practice Address - Street 1:1315 NW 4TH ST APT B
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1328
Practice Address - Country:US
Practice Address - Phone:541-504-2350
Practice Address - Fax:541-504-2354
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05114225100000X
WAPT00009847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8432429Medicaid
OR8432429Medicaid
WA8855332Medicare ID - Type Unspecified
WA8432429Medicaid