Provider Demographics
NPI:1700622131
Name:ODELUS, HERBO
Entity type:Individual
Prefix:
First Name:HERBO
Middle Name:
Last Name:ODELUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 CAPTAINS WALK APT A
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-6929
Mailing Address - Country:US
Mailing Address - Phone:786-274-9650
Mailing Address - Fax:
Practice Address - Street 1:1451 CAPTAINS WALK APT A
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-6929
Practice Address - Country:US
Practice Address - Phone:786-274-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-04
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-358942106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician