Provider Demographics
NPI:1710687983
Name:ODNEAL, KRISTIN (EDS)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:ODNEAL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:HAYWARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDS
Mailing Address - Street 1:1818 W WORLEY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 W WORLEY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1038
Practice Address - Country:US
Practice Address - Phone:573-214-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO52829103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool