Healthcare Provider Details

I. General information

NPI: 1740469626
Provider Name (Legal Business Name): SHARON RENEE ODOM M.S. MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 WYLIE DR STE 9
MODESTO CA
95355-3847
US

IV. Provider business mailing address

PO BOX 578601
MODESTO CA
95357-8601
US

V. Phone/Fax

Practice location:
  • Phone: 209-450-4265
  • Fax: 209-579-5710
Mailing address:
  • Phone: 209-450-6245
  • Fax: 209-579-5710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number42146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: