Provider Demographics
NPI:1285639476
Name:BRACY, ODIE L III (PHD)
Entity Type:Individual
Prefix:DR
First Name:ODIE
Middle Name:L
Last Name:BRACY
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1664
Mailing Address - Country:US
Mailing Address - Phone:317-257-9672
Mailing Address - Fax:317-257-9674
Practice Address - Street 1:6555 CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1664
Practice Address - Country:US
Practice Address - Phone:317-257-9672
Practice Address - Fax:317-257-9674
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010368A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000085922OtherANTHEM BC/BS
IN100073260Medicaid
IN100073260Medicaid