Healthcare Provider Details

I. General information

NPI: 1275135584
Provider Name (Legal Business Name): RAYMOND C ODIAKA PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAY ST
ATTLEBORO MA
02703-5520
US

IV. Provider business mailing address

4015 HAWTHORNE DR
SACHSE TX
75048-4087
US

V. Phone/Fax

Practice location:
  • Phone: 508-761-8500
  • Fax:
Mailing address:
  • Phone: 972-804-3712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1018584
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: