Provider Demographics
NPI:1851835060
Name:ODUM, KACEY ELIZABETH (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:KACEY
Middle Name:ELIZABETH
Last Name:ODUM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 SOMBRILLO CT
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3259
Mailing Address - Country:US
Mailing Address - Phone:904-535-4991
Mailing Address - Fax:
Practice Address - Street 1:1011 SOMBRILLO CT
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3259
Practice Address - Country:US
Practice Address - Phone:505-661-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12208224Z00000X
KS18-01385224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant