Healthcare Provider Details

I. General information

NPI: 1861117897
Provider Name (Legal Business Name): EMILY ODDO LCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 BECKNER RD STE 2750
SANTA FE NM
87507-3641
US

IV. Provider business mailing address

955 RICHARDS AVE APT 3041
SANTA FE NM
87507-6220
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-2560
  • Fax:
Mailing address:
  • Phone: 719-371-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC2022-041
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: