Provider Demographics
NPI:1891316733
Name:ODEN, TYNESHA
Entity Type:Individual
Prefix:
First Name:TYNESHA
Middle Name:
Last Name:ODEN
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 1:402 SKYLINE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-6043
Mailing Address - Country:US
Mailing Address - Phone:618-799-5621
Mailing Address - Fax:
Practice Address - Street 1:402 SKYLINE VIEW DR
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-6043
Practice Address - Country:US
Practice Address - Phone:618-799-5621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician