Provider Demographics
NPI:1720352305
Name:ODOMS, KEALA LASHAUN (MSHSA, OTR/L)
Entity Type:Individual
Prefix:
First Name:KEALA
Middle Name:LASHAUN
Last Name:ODOMS
Suffix:
Gender:F
Credentials:MSHSA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6769 DEER FOOT DR
Mailing Address - Street 2:
Mailing Address - City:PINSON
Mailing Address - State:AL
Mailing Address - Zip Code:35126-6202
Mailing Address - Country:US
Mailing Address - Phone:205-305-7120
Mailing Address - Fax:
Practice Address - Street 1:3605 RATLIFF RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35210-4512
Practice Address - Country:US
Practice Address - Phone:205-956-7133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2059225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2059OtherLICENSURE / CERTIFICATION BOARD FOR OCCUPATIONAL THERAPY