Provider Demographics
NPI:1073057394
Name:VICKERY-MERRIGAN, ODESSA LEE
Entity Type:Individual
Prefix:MRS
First Name:ODESSA
Middle Name:LEE
Last Name:VICKERY-MERRIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ODESSA
Other - Middle Name:LEE
Other - Last Name:VICKERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9208 PALOS VERDE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-8048
Mailing Address - Country:US
Mailing Address - Phone:407-415-2094
Mailing Address - Fax:
Practice Address - Street 1:9208 PALOS VERDE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-8048
Practice Address - Country:US
Practice Address - Phone:407-415-2094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW105551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical