Provider Demographics
NPI:1659252971
Name:O'DEA, CHASITY NICOLE (LMBT)
Entity type:Individual
Prefix:
First Name:CHASITY
Middle Name:NICOLE
Last Name:O'DEA
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 MCKINNON FARM RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-8918
Mailing Address - Country:US
Mailing Address - Phone:270-889-8434
Mailing Address - Fax:
Practice Address - Street 1:823 ELM ST STE 234
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4172
Practice Address - Country:US
Practice Address - Phone:270-889-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22858225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty