Provider Demographics
NPI:1164318416
Name:ODREN, TYREANNA
Entity type:Individual
Prefix:
First Name:TYREANNA
Middle Name:
Last Name:ODREN
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 1:1415 PRAIRIE PKWY SW UNIT 116
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-2793
Mailing Address - Country:US
Mailing Address - Phone:616-385-8235
Mailing Address - Fax:
Practice Address - Street 1:2920 FULLER AVE NE STE 203
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3458
Practice Address - Country:US
Practice Address - Phone:616-217-9421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-14
Last Update Date:2025-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851117960104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker