Provider Demographics
NPI:1760891493
Name:ODEM, THEODORE JR
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:ODEM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 N MAGNOLIA AVE
Mailing Address - Street 2:APT. 1614
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-1667
Mailing Address - Country:US
Mailing Address - Phone:407-765-7138
Mailing Address - Fax:
Practice Address - Street 1:335 N MAGNOLIA AVE
Practice Address - Street 2:APT. 1614
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-1667
Practice Address - Country:US
Practice Address - Phone:407-765-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker