Provider Demographics
NPI:1184599714
Name:ODOM, HAILEY MICHEAL
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:MICHEAL
Last Name:ODOM
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 1:521 N MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-2429
Mailing Address - Country:US
Mailing Address - Phone:812-557-7386
Mailing Address - Fax:
Practice Address - Street 1:2614 CHARLESTOWN RD.
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3310
Practice Address - Country:US
Practice Address - Phone:930-204-2414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician