Provider Demographics
NPI:1942463989
Name:ODOM, PAGE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PAGE
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:8288 TELEGRAPH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1130
Mailing Address - Country:US
Mailing Address - Phone:410-305-0158
Mailing Address - Fax:410-305-0159
Practice Address - Street 1:8288 TELEGRAPH RD
Practice Address - Street 2:SUITE A
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1130
Practice Address - Country:US
Practice Address - Phone:410-305-0158
Practice Address - Fax:410-305-0159
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04143103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11833482OtherCAQH