Healthcare Provider Details

I. General information

NPI: 1306910781
Provider Name (Legal Business Name): MR. ANYA ONUOHA ODIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 WESTGATE DR SUITE 604
DURHAM NC
27707-2567
US

IV. Provider business mailing address

4520 SHADY SIDE LN
DURHAM NC
27713-3127
US

V. Phone/Fax

Practice location:
  • Phone: 919-451-6337
  • Fax: 919-484-1125
Mailing address:
  • Phone: 919-451-6337
  • Fax: 919-484-1125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2596
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2596
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2596
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2596
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2596
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: