Provider Demographics
NPI:1366847097
Name:ODENAT, LYDIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:ODENAT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 WALKER RIDGE DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4192
Mailing Address - Country:US
Mailing Address - Phone:678-687-9149
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD SE BLDG 18-250
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9461
Practice Address - Country:US
Practice Address - Phone:678-687-9149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003854103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral