Provider Demographics
NPI:1790161701
Name:ODIASE, PHILOMENA
Entity Type:Individual
Prefix:
First Name:PHILOMENA
Middle Name:
Last Name:ODIASE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S DANTE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-2045
Mailing Address - Country:US
Mailing Address - Phone:708-915-0920
Mailing Address - Fax:708-960-0023
Practice Address - Street 1:441 S DANTE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-2045
Practice Address - Country:US
Practice Address - Phone:708-915-0920
Practice Address - Fax:708-960-0023
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health