Healthcare Provider Details

I. General information

NPI: 1508485236
Provider Name (Legal Business Name): KRISTEN ODDI BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HIGHTOWER TRL STE B120
SANDY SPRINGS GA
30350-6205
US

IV. Provider business mailing address

PO BOX 399318
SAN FRANCISCO CA
94139-9318
US

V. Phone/Fax

Practice location:
  • Phone: 912-312-3407
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-35218
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-43302
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: