Provider Demographics
NPI:1154020451
Name:THOMAS-ODEN, IMANI A
Entity type:Individual
Prefix:MRS
First Name:IMANI
Middle Name:A
Last Name:THOMAS-ODEN
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 1:3557 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-2624
Mailing Address - Country:US
Mailing Address - Phone:404-398-2622
Mailing Address - Fax:
Practice Address - Street 1:259 ARROWHEAD BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1167
Practice Address - Country:US
Practice Address - Phone:770-685-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2025-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-25-85951103K00000X
GABACB836741106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician