Provider Demographics
NPI:1831373539
Name:ODEN, DEBRA RAE (LMT)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:RAE
Last Name:ODEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 N. AMHERST DR
Mailing Address - Street 2:
Mailing Address - City:PORTAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203
Mailing Address - Country:US
Mailing Address - Phone:503-910-5717
Mailing Address - Fax:
Practice Address - Street 1:8538 SW APPLEWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-520-8743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR203005146N00000X
OR8030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic