Provider Demographics
NPI:1134734452
Name:ODZIANA, KAYCEE (PTA)
Entity type:Individual
Prefix:
First Name:KAYCEE
Middle Name:
Last Name:ODZIANA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52503 STAFFORD DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-3816
Mailing Address - Country:US
Mailing Address - Phone:586-430-1333
Mailing Address - Fax:586-430-4691
Practice Address - Street 1:52503 STAFFORD DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-3816
Practice Address - Country:US
Practice Address - Phone:586-430-1333
Practice Address - Fax:586-430-4691
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003709225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant