Provider Demographics
NPI:1932748068
Name:ODOM, KEVIN EUGENE (CCS-I, LCAS, LCMHC-A)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:EUGENE
Last Name:ODOM
Suffix:
Gender:M
Credentials:CCS-I, LCAS, LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 S TWIN HILL RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-6740
Mailing Address - Country:US
Mailing Address - Phone:252-686-3025
Mailing Address - Fax:
Practice Address - Street 1:231 S TWIN HILL RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-6740
Practice Address - Country:US
Practice Address - Phone:252-686-3025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2023-02-14
Deactivation Date:2020-01-28
Deactivation Code:
Reactivation Date:2020-02-20
Provider Licenses
StateLicense IDTaxonomies
NCLCMHC-A16107101YM0800X
NCLCAS-26159101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health