Provider Demographics
NPI:1861946469
Name:O'DELL, KALLIE
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:O'DELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9571
Mailing Address - Country:US
Mailing Address - Phone:816-261-9893
Mailing Address - Fax:
Practice Address - Street 1:925 FELIX ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64501-2788
Practice Address - Country:US
Practice Address - Phone:816-671-4007
Practice Address - Fax:816-671-4470
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016027708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist