Provider Demographics
NPI:1598175515
Name:ODOM, KENNETH (MA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-8659
Mailing Address - Country:US
Mailing Address - Phone:719-315-2254
Mailing Address - Fax:
Practice Address - Street 1:3239 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9380
Practice Address - Country:US
Practice Address - Phone:719-275-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor