Provider Demographics
NPI:1689008609
Name:ODUM, IESHA (MS, CAADC, LPC)
Entity type:Individual
Prefix:MS
First Name:IESHA
Middle Name:
Last Name:ODUM
Suffix:
Gender:F
Credentials:MS, CAADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4825
Mailing Address - Country:US
Mailing Address - Phone:313-396-5300
Mailing Address - Fax:
Practice Address - Street 1:2925 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4825
Practice Address - Country:US
Practice Address - Phone:248-747-2798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013850101YP2500X, 101Y00000X
101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health