Provider Demographics
NPI:1376826719
Name:HANCOCK, ODESSA MAVIS THOMAS (LCSW)
Entity type:Individual
Prefix:MISS
First Name:ODESSA
Middle Name:MAVIS THOMAS
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13395 N MARANA MAIN ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-7008
Mailing Address - Country:US
Mailing Address - Phone:520-682-1091
Mailing Address - Fax:
Practice Address - Street 1:13395 N MARANA MAIN ST BLDG B
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7008
Practice Address - Country:US
Practice Address - Phone:520-682-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP005543104100000X
NCP015881104100000X
AZLMSW-19637104100000X
NC12170851041S0200X
AZLCSW-223531041C0700X
NCLCAS-15573101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)