Provider Demographics
NPI:1588191647
Name:ODLE, ERICA (LMT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:ODLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:DEPOE BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97341-0512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 E COLLINS ST APT 4
Practice Address - Street 2:
Practice Address - City:DEPOE BAY
Practice Address - State:OR
Practice Address - Zip Code:97341-1924
Practice Address - Country:US
Practice Address - Phone:541-961-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21072225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist