Provider Demographics
NPI:1831320456
Name:ODOM, BENJAMIN SCOTT (LPC/APRN)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:SCOTT
Last Name:ODOM
Suffix:
Gender:M
Credentials:LPC/APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WINNIE
Mailing Address - State:TX
Mailing Address - Zip Code:77665-7600
Mailing Address - Country:US
Mailing Address - Phone:318-614-2241
Mailing Address - Fax:
Practice Address - Street 1:538 BROADWAY
Practice Address - Street 2:
Practice Address - City:WINNIE
Practice Address - State:TX
Practice Address - Zip Code:77665-7600
Practice Address - Country:US
Practice Address - Phone:409-296-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63792101YP2500X
TX1098056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1098056OtherTEXAS LICENSE APRN