Provider Demographics
NPI:1154768943
Name:ODESEYE, GBEMISOLA KIKELOMO (DPT)
Entity type:Individual
Prefix:
First Name:GBEMISOLA
Middle Name:KIKELOMO
Last Name:ODESEYE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 MCKAVETT DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-9302
Mailing Address - Country:US
Mailing Address - Phone:410-802-0730
Mailing Address - Fax:
Practice Address - Street 1:301 HUGULEY BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7506
Practice Address - Country:US
Practice Address - Phone:410-802-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCP014752TOtherTEXAS BOARD OF PHYSICAL THERAPY
MD24478OtherBOARD OF PHYSICAL THERAPY, MARYLAND