Provider Demographics
NPI:1831554641
Name:ODYSSEY THERAPEUTICS
Entity type:Organization
Organization Name:ODYSSEY THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:360-820-0954
Mailing Address - Street 1:15018 113TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-3408
Mailing Address - Country:US
Mailing Address - Phone:360-820-0954
Mailing Address - Fax:253-881-1017
Practice Address - Street 1:15111 105TH AVENUE CT E
Practice Address - Street 2:STE. 2
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-3747
Practice Address - Country:US
Practice Address - Phone:360-820-0954
Practice Address - Fax:253-881-1017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty