Provider Demographics
NPI:1821552084
Name:ODOMS, TA'SHEMA NICOLE (LPC)
Entity Type:Individual
Prefix:MS
First Name:TA'SHEMA
Middle Name:NICOLE
Last Name:ODOMS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 WEST ST APT 20
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-2936
Mailing Address - Country:US
Mailing Address - Phone:860-878-1696
Mailing Address - Fax:
Practice Address - Street 1:469 BUCKLAND RD STE 104
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3737
Practice Address - Country:US
Practice Address - Phone:860-878-1696
Practice Address - Fax:860-432-4540
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3332101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional