Healthcare Provider Details

I. General information

NPI: 1780384982
Provider Name (Legal Business Name): SHARON LISA ODOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 NE MAIN ST STE A
SIMPSONVILLE SC
29681-2056
US

IV. Provider business mailing address

4595 LEXINGTON AVE
JACKSONVILLE FL
32210-2058
US

V. Phone/Fax

Practice location:
  • Phone: 864-688-9416
  • Fax:
Mailing address:
  • Phone: 904-448-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8037
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: