MEDICARE: MARILYN DIANE ODOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	13856	CA

General Provider Information

NPI Number	:	1093564973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN DIANE ODOM

Provider Business Mailing Address
First Line	:	250 E BROADWAY APT 505
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-6265
Country	:	US
Telephone Number	:	707-653-0294
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 E BROADWAY APT 505
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-6265
Country	:	US
Telephone Number	:	707-653-0294
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2024
Last Update Date	:	07/12/2024

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Directions to “ MARILYN DIANE ODOM ” Practice Location

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