Provider Demographics
NPI:1922582634
Name:ODOM, TAVUNDA LASHAE (BS)
Entity Type:Individual
Prefix:
First Name:TAVUNDA
Middle Name:LASHAE
Last Name:ODOM
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 N ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-9179
Mailing Address - Country:US
Mailing Address - Phone:863-368-1547
Mailing Address - Fax:
Practice Address - Street 1:1975 S JOHN YOUNG PKWY STE 203A
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0603
Practice Address - Country:US
Practice Address - Phone:407-486-7826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker