Provider Demographics
NPI:1962603480
Name:ODOM, LESLIE M (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:ODOM
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:GA
Mailing Address - Zip Code:39842-4126
Mailing Address - Country:US
Mailing Address - Phone:229-881-3037
Mailing Address - Fax:
Practice Address - Street 1:2411 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2225
Practice Address - Country:US
Practice Address - Phone:229-461-5926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006243235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA795771487BMedicaid