Provider Demographics
NPI:1063799492
Name:ODELL, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ODELL
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 1:4328 S FORRESTVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 S MAIN ST
Practice Address - Street 2:SUITE 220
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2089
Practice Address - Country:US
Practice Address - Phone:773-549-5294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003222235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist