Provider Demographics
NPI:1861696148
Name:ODIN, KATHLEEN C (PTA)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:C
Last Name:ODIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:DRAVELING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8780 RAINIER ALCOVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-428-3902
Mailing Address - Fax:
Practice Address - Street 1:2727 N VICTORIA
Practice Address - Street 2:LAKERIDGE HC CENTER AEGIS THERAPIES
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-483-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI250019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant