Provider Demographics
NPI:1396128799
Name:ODOM, CYNTHIA E (LMP)
Entity type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:E
Last Name:ODOM
Suffix:
Gender:F
Credentials:LMP
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 311
Mailing Address - Street 2:
Mailing Address - City:COWICHE
Mailing Address - State:WA
Mailing Address - Zip Code:98923-0311
Mailing Address - Country:US
Mailing Address - Phone:509-307-3116
Mailing Address - Fax:509-678-0260
Practice Address - Street 1:118 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3204
Practice Address - Country:US
Practice Address - Phone:509-307-3116
Practice Address - Fax:509-678-0260
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60562028225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist