Provider Demographics
NPI:1578052171
Name:ODANIEL, MARY ANNE E (PT)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:E
Last Name:ODANIEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY ANNE
Other - Middle Name:E
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:444 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431
Practice Address - Country:US
Practice Address - Phone:270-825-0069
Practice Address - Fax:270-824-9777
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007430225100000X
KYTP2018037225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100552180Medicaid