Healthcare Provider Details

I. General information

NPI: 1154020451
Provider Name (Legal Business Name): MRS. IMANI A THOMAS-ODEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 ARROWHEAD BLVD
JONESBORO GA
30236-1167
US

IV. Provider business mailing address

3557 MAIN ST
COLLEGE PARK GA
30337-2624
US

V. Phone/Fax

Practice location:
  • Phone: 770-685-5733
  • Fax:
Mailing address:
  • Phone: 404-398-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85951
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB836741
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: