Provider Demographics
NPI:1629246079
Name:ODOM, LOUISE ANNE (PT,)
Entity Type:Individual
Prefix:MRS
First Name:LOUISE
Middle Name:ANNE
Last Name:ODOM
Suffix:
Gender:F
Credentials:PT,
Other - Prefix:MISS
Other - First Name:LOUISE
Other - Middle Name:ANNE
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1580 HIGHWAY 287 N
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7593
Mailing Address - Country:US
Mailing Address - Phone:817-473-4684
Mailing Address - Fax:
Practice Address - Street 1:1580 HIGHWAY 287 N
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7593
Practice Address - Country:US
Practice Address - Phone:817-473-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1083277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist