=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487795951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER RACHEL NELSON-ODODA LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13 N BROAD ST SUITE 2-B
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-1972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-868-8737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 BASKINS CIR
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-3582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-868-8737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW003407
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------