Provider Demographics
NPI:1326583949
Name:O'DELL, CORISSA (QASP)
Entity Type:Individual
Prefix:
First Name:CORISSA
Middle Name:
Last Name:O'DELL
Suffix:
Gender:F
Credentials:QASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 MOUNTAIN LION CIR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-5724
Mailing Address - Country:US
Mailing Address - Phone:254-213-1924
Mailing Address - Fax:
Practice Address - Street 1:904 MOUNTAIN LION CIR
Practice Address - Street 2:SUITE 500
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-5724
Practice Address - Country:US
Practice Address - Phone:254-213-1924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
1-17-26816103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst