Provider Demographics
NPI:1417595299
Name:ODOM, KARILYN ALYSE
Entity Type:Individual
Prefix:
First Name:KARILYN
Middle Name:ALYSE
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1181 S SUNKIST ST APT 45
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3050 SATURN ST STE 102
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6281
Practice Address - Country:US
Practice Address - Phone:657-444-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician