Provider Demographics
NPI:1043481195
Name:ODOM, SUSAN DEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DEAN
Last Name:ODOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13423 BLANCO RD UNIT 803
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2187
Mailing Address - Country:US
Mailing Address - Phone:210-557-2266
Mailing Address - Fax:210-624-8789
Practice Address - Street 1:13423 BLANCO RD UNIT 803
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2187
Practice Address - Country:US
Practice Address - Phone:210-689-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33728103TB0200X, 103TC1900X, 103TH0004X, 103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth