Provider Demographics
NPI:1386068476
Name:ODEN, NAA Y (BCBA, NCSP)
Entity type:Individual
Prefix:
First Name:NAA
Middle Name:Y
Last Name:ODEN
Suffix:
Gender:F
Credentials:BCBA, NCSP
Other - Prefix:
Other - First Name:NAIA
Other - Middle Name:Y
Other - Last Name:ODEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4813 RIDGE RD STE 111-639
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-6117
Mailing Address - Country:US
Mailing Address - Phone:330-622-3766
Mailing Address - Fax:404-225-1840
Practice Address - Street 1:4813 RIDGE RD STE 111-639
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:330-622-3766
Practice Address - Fax:404-225-1840
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3043645103TS0200X
GA1-19-35830103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty