Basic Information
| Provider Information | |||||||||
| NPI: | 1720260102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DELL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 S CANNON BLVD | ||||||||
| Address2: | |||||||||
| City: | KANNAPOLIS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280836232 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 W ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281102818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042966200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 01/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C005296 | NC | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6106809 | 05 | NC | MEDICAID | 147NF | 01 | NC | BCBS | OTHER |