Provider Demographics
NPI:1417570805
Name:ODOM, PATRICK RYAN (LADC)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:RYAN
Last Name:ODOM
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-4065
Mailing Address - Country:US
Mailing Address - Phone:507-282-0142
Mailing Address - Fax:507-282-6261
Practice Address - Street 1:2360 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-4065
Practice Address - Country:US
Practice Address - Phone:507-282-0142
Practice Address - Fax:507-282-6261
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305643101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)