Provider Demographics
NPI:1801390166
Name:ODOM, KEAH
Entity Type:Individual
Prefix:
First Name:KEAH
Middle Name:
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 1:3840 HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16160 MIDWAY RD STE 218
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4207
Practice Address - Country:US
Practice Address - Phone:469-690-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical