Basic Information
| Provider Information | |||||||||
| NPI: | 1689008609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODUM | ||||||||
| FirstName: | IESHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, CAADC, LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3138312608 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3138312608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2013 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | 6401013850 | MI | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 6401013850 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.