Provider Demographics
NPI:1013407436
Name:O'DELL, ELIDETH
Entity Type:Individual
Prefix:
First Name:ELIDETH
Middle Name:
Last Name:O'DELL
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 1:91-2301 OLD FT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3602
Mailing Address - Country:US
Mailing Address - Phone:808-671-8511
Mailing Address - Fax:
Practice Address - Street 1:91-2301 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3602
Practice Address - Country:US
Practice Address - Phone:808-677-2819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI104100000X
390200000X
HILCSW-49131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program