Provider Demographics
NPI:1164991444
Name:ODOM, KIARA
Entity Type:Individual
Prefix:MS
First Name:KIARA
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 CEDARWOOD LN APT G
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8497
Mailing Address - Country:US
Mailing Address - Phone:704-818-1839
Mailing Address - Fax:
Practice Address - Street 1:705 S KERR AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8425
Practice Address - Country:US
Practice Address - Phone:704-819-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty