Basic Information
| Provider Information | |||||||||
| NPI: | 1316067218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | KATINA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | BSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11883 | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337331883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274206147 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 7TH AVE S | ||||||||
| Address2: | DEPT. 7470 | ||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674403 | ||||||||
| FaxNumber: | 7277674715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.