Provider Demographics
NPI:1982006268
Name:ODUM, LESLI
Entity Type:Individual
Prefix:MRS
First Name:LESLI
Middle Name:
Last Name:ODUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 MONTGOMERY RD UNIT 279
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7420
Mailing Address - Country:US
Mailing Address - Phone:407-801-9628
Mailing Address - Fax:
Practice Address - Street 1:6396 ROYAL TERN ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-6012
Practice Address - Country:US
Practice Address - Phone:407-801-9628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X, 261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health