Healthcare Provider Details

I. General information

NPI: 1366847097
Provider Name (Legal Business Name): LYDIA ODENAT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 POWERS FERRY RD SE BLDG 18-250
MARIETTA GA
30067-9461
US

IV. Provider business mailing address

1777 WALKER RIDGE DR SW
MARIETTA GA
30064-4192
US

V. Phone/Fax

Practice location:
  • Phone: 678-687-9149
  • Fax:
Mailing address:
  • Phone: 678-687-9149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY003854
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: