Provider Demographics
NPI:1033843719
Name:ODEN, SHOMARI
Entity Type:Individual
Prefix:
First Name:SHOMARI
Middle Name:
Last Name:ODEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5448 BASS PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-6370
Mailing Address - Country:US
Mailing Address - Phone:240-565-9093
Mailing Address - Fax:
Practice Address - Street 1:5201 HAYES ST NE APT 327
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-5572
Practice Address - Country:US
Practice Address - Phone:202-489-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-10
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCNONEMedicaid