=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861117897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY ODDO LCGC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4801 BECKNER RD STE 2750
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-984-2560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 RICHARDS AVE APT 3041
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-6220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-371-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 170300000X
-----------------------------------------------------
Taxonomy Name | Genetic Counselor (M.S.)
-----------------------------------------------------
License Number | GC2022-041
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------