Provider Demographics
NPI:1891197091
Name:ODOM, TANYA NICOLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:NICOLE
Last Name:ODOM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 MCCLELLAN CIR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-3024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 WESLEY ST
Practice Address - Street 2:SUITE 8
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1740
Practice Address - Country:US
Practice Address - Phone:423-282-1700
Practice Address - Fax:423-282-9319
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5051235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist