Provider Demographics
NPI:1407592637
Name:ODOM, NAKITA RICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:NAKITA
Middle Name:RICHELLE
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 1:2510 MARION LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-2325
Mailing Address - Country:US
Mailing Address - Phone:731-803-4581
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94921041C0700X
TN13362104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical