Provider Demographics
NPI:1275135584
Name:ODIAKA, RAYMOND C (PMHNP)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:C
Last Name:ODIAKA
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:SACHSE
Mailing Address - State:TX
Mailing Address - Zip Code:75048-4087
Mailing Address - Country:US
Mailing Address - Phone:972-804-3712
Mailing Address - Fax:
Practice Address - Street 1:7272 WURZBACH RD STE 601
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4803
Practice Address - Country:US
Practice Address - Phone:210-615-3483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1018584363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty