Basic Information
| Provider Information | |||||||||
| NPI: | 1275135584 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODIAKA | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4015 HAWTHORNE DR | ||||||||
| Address2: | |||||||||
| City: | SACHSE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750484087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728043712 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7272 WURZBACH RD STE 601 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2020 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 1018584 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.