Provider Demographics
NPI:1588214068
Name:ODUM, OMNI (LLPC)
Entity Type:Individual
Prefix:
First Name:OMNI
Middle Name:
Last Name:ODUM
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21137 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3860
Mailing Address - Country:US
Mailing Address - Phone:810-288-3475
Mailing Address - Fax:
Practice Address - Street 1:1121 VILLA LINDE CT BLDG 39
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3410
Practice Address - Country:US
Practice Address - Phone:810-515-1931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional