Provider Demographics
NPI:1063711315
Name:ODOM, KANDICE TOPAZ (CMT)
Entity type:Individual
Prefix:
First Name:KANDICE
Middle Name:TOPAZ
Last Name:ODOM
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MURYLU DR
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-3904
Mailing Address - Country:US
Mailing Address - Phone:201-938-2778
Mailing Address - Fax:
Practice Address - Street 1:205 ROBIN RD
Practice Address - Street 2:SUITE 118
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1449
Practice Address - Country:US
Practice Address - Phone:201-225-1511
Practice Address - Fax:201-225-9731
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26BT00231600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist