Provider Demographics
NPI:1285183517
Name:ODOM, TIJUANA (LCSW)
Entity type:Individual
Prefix:
First Name:TIJUANA
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 5115 BOX 48TH
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09461-5115
Mailing Address - Country:US
Mailing Address - Phone:314-268-1505
Mailing Address - Fax:
Practice Address - Street 1:UNIT 3215
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094-3215
Practice Address - Country:US
Practice Address - Phone:314-479-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical