Provider Demographics
NPI:1609413210
Name:ODIN, AMY MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:ODIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4511
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-4511
Mailing Address - Country:US
Mailing Address - Phone:832-279-4035
Mailing Address - Fax:
Practice Address - Street 1:909 REINLI ST APT 133
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-1509
Practice Address - Country:US
Practice Address - Phone:832-279-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-1150211041C0700X
MTBBH-LCSW-LIC-378651041C0700X
TX609521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTBBH-LCSW-LIC-37865OtherLCSW
NMC-115021OtherLCSW
TX60952OtherLCSW-S