Healthcare Provider Details

I. General information

NPI: 1801401005
Provider Name (Legal Business Name): ODALYZ ABREO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE STE 301
LOS ANGELES CA
90059-3019
US

IV. Provider business mailing address

3035 GLENN AVE
LOS ANGELES CA
90023-2712
US

V. Phone/Fax

Practice location:
  • Phone: 888-777-8565
  • Fax:
Mailing address:
  • Phone: 323-875-8648
  • Fax: 323-875-8648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number390200000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: