Healthcare Provider Details

I. General information

NPI: 1073443792
Provider Name (Legal Business Name): KENISHA ODOMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GLENCREST LN STE A
LONGVIEW TX
75601-5145
US

IV. Provider business mailing address

701 GLENCREST LN STE A
LONGVIEW TX
75601-5145
US

V. Phone/Fax

Practice location:
  • Phone: 903-686-9941
  • Fax: 903-686-9941
Mailing address:
  • Phone: 903-686-9941
  • Fax: 903-686-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-414230
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: