Provider Demographics
NPI:1528600137
Name:ODOM, AMELIA L
Entity Type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:L
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 1:8 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-1345
Mailing Address - Country:US
Mailing Address - Phone:618-688-7100
Mailing Address - Fax:
Practice Address - Street 1:8 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1345
Practice Address - Country:US
Practice Address - Phone:618-688-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor