Provider Demographics
NPI:1881780542
Name:ODOM, MARK RICHARD (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:ODOM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 E 1ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-6341
Mailing Address - Country:US
Mailing Address - Phone:714-504-4124
Mailing Address - Fax:
Practice Address - Street 1:1540 E 1ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-6341
Practice Address - Country:US
Practice Address - Phone:714-972-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 187451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical