Provider Demographics
NPI:1215654835
Name:O'DEA, KATHERINE GAIL
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GAIL
Last Name:O'DEA
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 1:5935 WESTERN PARK DR APT D
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3450
Mailing Address - Country:US
Mailing Address - Phone:443-942-8189
Mailing Address - Fax:
Practice Address - Street 1:2501 SMITH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2505
Practice Address - Country:US
Practice Address - Phone:410-205-9493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD45004035200Medicaid