Provider Demographics
NPI:1194031823
Name:ODOM, CYNTHIA BRIANA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:BRIANA
Last Name:ODOM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:BRIANA
Other - Last Name:WAGLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2502 HEMPSTEAD 117
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-1081
Mailing Address - Country:US
Mailing Address - Phone:870-703-7945
Mailing Address - Fax:
Practice Address - Street 1:1102 N 10TH ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-3217
Practice Address - Country:US
Practice Address - Phone:870-703-7945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3556235Z00000X
TX104865235Z00000X
IA001969235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210848721Medicaid