Provider Demographics
NPI:1699080366
Name:DESPOT, ODESSA D
Entity type:Individual
Prefix:
First Name:ODESSA
Middle Name:D
Last Name:DESPOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2006
Practice Address - Country:US
Practice Address - Phone:585-922-4698
Practice Address - Fax:585-922-5702
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020147103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWVE061OtherAGENCY MEDICARE ID#
NY1285628552OtherAGENCY NPI#
NY00355940OtherAGENCY MEDICAID PROVIDER ID