Healthcare Provider Details

I. General information

NPI: 1619327947
Provider Name (Legal Business Name): AMBER NICOLE ODOM MSW, LCSW(CA 129938)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 FOWLER LN STE 204
DIAMOND SPRINGS CA
95619-9782
US

IV. Provider business mailing address

3600 DATA DR APT 57
RANCHO CORDOVA CA
95670-7907
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-3105
  • Fax:
Mailing address:
  • Phone: 703-853-0789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117372
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW129938
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: