Provider Demographics
NPI:1780195073
Name:ODOM, KATHERINE NICOLE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NICOLE
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 BAY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-1835
Mailing Address - Country:US
Mailing Address - Phone:774-218-4422
Mailing Address - Fax:
Practice Address - Street 1:287 BAY ST APT 1
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-1835
Practice Address - Country:US
Practice Address - Phone:774-218-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health