Provider Demographics
NPI:1891814646
Name:ODOM, PAMELA Y (LPC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:Y
Last Name:ODOM
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 1:1790 N LEE TREVINO DR
Mailing Address - Street 2:SUITE 601 A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4545
Mailing Address - Country:US
Mailing Address - Phone:915-778-4243
Mailing Address - Fax:915-778-4244
Practice Address - Street 1:1790 N LEE TREVINO DR
Practice Address - Street 2:SUITE 601 A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4545
Practice Address - Country:US
Practice Address - Phone:915-778-4243
Practice Address - Fax:915-778-4244
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63937101YP2500X
NM0068462101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15823881Medicaid
TX211916601Medicaid