Provider Demographics
NPI:1427219484
Name:ODOM, GARY
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 OCEANGATE
Mailing Address - Street 2:SUITE 550
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-2426
Mailing Address - Country:US
Mailing Address - Phone:562-713-2614
Mailing Address - Fax:
Practice Address - Street 1:100 OCEANGATE
Practice Address - Street 2:SUITE 550
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4312
Practice Address - Country:US
Practice Address - Phone:562-713-2614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336421041C0700X
CA715601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical