Provider Demographics
NPI:1992143960
Name:ODOM, ANDREW TYLER (BS)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:TYLER
Last Name:ODOM
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:ANDREW
Other - Middle Name:T
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:9196 W EMERALD ST STE 135
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8004
Mailing Address - Country:US
Mailing Address - Phone:208-323-4400
Mailing Address - Fax:
Practice Address - Street 1:9196 W EMERALD ST STE 135
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8004
Practice Address - Country:US
Practice Address - Phone:208-323-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker