Provider Demographics
NPI:1164035788
Name:ODOM, ALEXIS AMANDA
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:AMANDA
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 CRENSHAW BLVD STE E100
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-1728
Mailing Address - Country:US
Mailing Address - Phone:310-787-1500
Mailing Address - Fax:
Practice Address - Street 1:370 CRENSHAW BLVD STE E100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1728
Practice Address - Country:US
Practice Address - Phone:310-787-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW97483104100000X
CALCSW125834104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker