MEDICARE: JUSTIN GREGORY ODLE

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1760172449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN GREGORY ODLE

Provider Business Mailing Address
First Line	:	60 CARROLL AVE
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-2916
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	694 BEACH 20TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-3502
Country	:	US
Telephone Number	:	718-471-0982
Fax Number	:

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

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	05/19/2026

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Directions to “ JUSTIN GREGORY ODLE ” Practice Location

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