Provider Demographics
NPI:1710596390
Name:GADE, ODYSSEY
Entity Type:Individual
Prefix:
First Name:ODYSSEY
Middle Name:
Last Name:GADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1141
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224
Mailing Address - Country:US
Mailing Address - Phone:206-858-3515
Mailing Address - Fax:
Practice Address - Street 1:426 BELLEVIEW AVE SUITE 100
Practice Address - Street 2:
Practice Address - City:CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81224
Practice Address - Country:US
Practice Address - Phone:206-858-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0023181225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist