Provider Demographics
NPI:1649817628
Name:ODOM, SUZANNE MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:ODOM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 LEMOYNE AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-1211
Mailing Address - Country:US
Mailing Address - Phone:315-200-2024
Mailing Address - Fax:
Practice Address - Street 1:1525 WESTERN AVE STE 4
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3537
Practice Address - Country:US
Practice Address - Phone:518-289-0426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09144651104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker