Provider Demographics
NPI:1689216483
Name:ODOM, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-2814
Mailing Address - Country:US
Mailing Address - Phone:507-236-1889
Mailing Address - Fax:
Practice Address - Street 1:213 E 2ND ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-2814
Practice Address - Country:US
Practice Address - Phone:507-236-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302138101YA0400X
MN2346101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)