Provider Demographics
NPI:1831691310
Name:ODLE, MICHAEL RYAN (SCHOOL PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:ODLE
Suffix:
Gender:M
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36716 OAK POINT RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478
Mailing Address - Country:US
Mailing Address - Phone:541-255-8463
Mailing Address - Fax:
Practice Address - Street 1:36716 OAK POINT RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478
Practice Address - Country:US
Practice Address - Phone:541-255-8463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10478961103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22667OtherACE-AMERICAN INSURANCE COMPANY