Provider Demographics
NPI:1083460786
Name:ODOM, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:ODOM
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 1:400 NE PINEAPPLE ST
Mailing Address - Street 2:
Mailing Address - City:PINETTA
Mailing Address - State:FL
Mailing Address - Zip Code:32350-2302
Mailing Address - Country:US
Mailing Address - Phone:850-253-5984
Mailing Address - Fax:
Practice Address - Street 1:20311 CENTRAL AVE W
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1947
Practice Address - Country:US
Practice Address - Phone:850-674-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health