Healthcare Provider Details

I. General information

NPI: 1649128539
Provider Name (Legal Business Name): EBONY ELISE ODOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3666 PARKMOOR VILLAGE DR APT B
COLORADO SPRINGS CO
80917-5210
US

IV. Provider business mailing address

3666 PARKMOOR VILLAGE DR APT B
COLORADO SPRINGS CO
80917-5210
US

V. Phone/Fax

Practice location:
  • Phone: 719-412-5982
  • Fax:
Mailing address:
  • Phone: 719-412-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: