Provider Demographics
NPI:1255118725
Name:O'DEA, KENNETH DANIEL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DANIEL
Last Name:O'DEA
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11775 SE MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3914
Mailing Address - Country:US
Mailing Address - Phone:650-740-9563
Mailing Address - Fax:
Practice Address - Street 1:366 N HOLLY ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3739
Practice Address - Country:US
Practice Address - Phone:503-908-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16852235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist