Provider Demographics
NPI:1669495594
Name:ODREN, DONELLE LEE (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:DONELLE
Middle Name:LEE
Last Name:ODREN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11915 E BROADWAY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4997
Mailing Address - Country:US
Mailing Address - Phone:509-921-7818
Mailing Address - Fax:509-891-0456
Practice Address - Street 1:11915 E BROADWAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4997
Practice Address - Country:US
Practice Address - Phone:509-921-7818
Practice Address - Fax:509-891-0456
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1669495594Medicaid
ID000010173043OtherREGENCE
ID16528071Medicare PIN
ID1652807Medicare PIN