Provider Demographics
NPI:1356762249
Name:ODETIN, MARIE PELAGIE (CRT)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:PELAGIE
Last Name:ODETIN
Suffix:
Gender:F
Credentials:CRT
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:PELAGIE
Other - Last Name:JEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRT
Mailing Address - Street 1:236 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-7829
Mailing Address - Country:US
Mailing Address - Phone:978-317-8711
Mailing Address - Fax:
Practice Address - Street 1:236 CROSS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-7829
Practice Address - Country:US
Practice Address - Phone:978-317-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT15564227800000X
MART5529227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified