Provider Demographics
NPI:1629844089
Name:ODOM, MCKINLEY (DPT)
Entity Type:Individual
Prefix:
First Name:MCKINLEY
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 SILVERPOINT RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-7963
Mailing Address - Country:US
Mailing Address - Phone:803-543-6979
Mailing Address - Fax:
Practice Address - Street 1:1711 LAKESIDE AVE STE 5
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4103
Practice Address - Country:US
Practice Address - Phone:904-679-3449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist