Provider Demographics
NPI:1316929060
Name:ODEN, MARCELLA RAQUEL (PT, DPT, DACM, LAC)
Entity type:Individual
Prefix:
First Name:MARCELLA
Middle Name:RAQUEL
Last Name:ODEN
Suffix:
Gender:F
Credentials:PT, DPT, DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 B AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1925
Mailing Address - Country:US
Mailing Address - Phone:808-783-4330
Mailing Address - Fax:
Practice Address - Street 1:4415 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-3005
Practice Address - Country:US
Practice Address - Phone:619-800-1974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277892251X0800X
CA19467171100000X
CAPT27789171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19467OtherACUPUNCTURE LICENSE
FLAP4491OtherACUPUNCTURE LICENSE
CAPT27789OtherPHYSICAL THERAPY LICENSE