Provider Demographics
NPI:1780242701
Name:O'DELL, THORN
Entity type:Individual
Prefix:MR
First Name:THORN
Middle Name:
Last Name:O'DELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THORN
Other - Middle Name:
Other - Last Name:O'DELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4325 N RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3438
Mailing Address - Country:US
Mailing Address - Phone:702-820-8891
Mailing Address - Fax:
Practice Address - Street 1:4325 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3438
Practice Address - Country:US
Practice Address - Phone:702-820-8891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty