Provider Demographics
NPI:1366259681
Name:EDIONWELE, ODION
Entity type:Individual
Prefix:
First Name:ODION
Middle Name:
Last Name:EDIONWELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 SOUTHGATE SQ # 1051
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3611
Mailing Address - Country:US
Mailing Address - Phone:757-774-6870
Mailing Address - Fax:
Practice Address - Street 1:84 SOUTHGATE SQ # 1051
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3611
Practice Address - Country:US
Practice Address - Phone:757-774-6870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040177501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical