Provider Demographics
NPI:1538600408
Name:ODOM, KRISTY
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
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 1:124 S MAIN ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3599
Mailing Address - Country:US
Mailing Address - Phone:678-765-9286
Mailing Address - Fax:
Practice Address - Street 1:124 S MAIN ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3599
Practice Address - Country:US
Practice Address - Phone:678-765-9286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009041101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional