Provider Demographics
NPI:1316303761
Name:ODOM, KOUSALYA (MA)
Entity type:Individual
Prefix:
First Name:KOUSALYA
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 TEAL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-7229
Mailing Address - Country:US
Mailing Address - Phone:270-202-7525
Mailing Address - Fax:
Practice Address - Street 1:9940 ALVATON RD
Practice Address - Street 2:
Practice Address - City:ALVATON
Practice Address - State:KY
Practice Address - Zip Code:42122-9657
Practice Address - Country:US
Practice Address - Phone:270-702-8970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor