Provider Demographics
NPI:1306910781
Name:ODIM, ANYA ONUOHA
Entity type:Individual
Prefix:MR
First Name:ANYA
Middle Name:ONUOHA
Last Name:ODIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 SHADY SIDE LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-3127
Mailing Address - Country:US
Mailing Address - Phone:919-451-6337
Mailing Address - Fax:919-484-1125
Practice Address - Street 1:3500 WESTGATE DR
Practice Address - Street 2:SUITE 604
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2567
Practice Address - Country:US
Practice Address - Phone:919-451-6337
Practice Address - Fax:919-484-1125
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2596103T00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107416Medicaid