Provider Demographics
NPI:1962796433
Name:O'DELL, AMY (MED, LPC, TRS, CNC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:O'DELL
Suffix:
Gender:F
Credentials:MED, LPC, TRS, CNC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:O'DELL-WUTTKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LPC, TRS, CNC
Mailing Address - Street 1:407 HARDSCRABBLE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1417
Mailing Address - Country:US
Mailing Address - Phone:770-998-1017
Mailing Address - Fax:770-998-3258
Practice Address - Street 1:407 HARDSCRABBLE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1417
Practice Address - Country:US
Practice Address - Phone:770-998-1017
Practice Address - Fax:770-998-3258
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004163101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional