Provider Demographics
NPI:1710242532
Name:O'DEA, CLAIRISSA M (LAC)
Entity type:Individual
Prefix:MS
First Name:CLAIRISSA
Middle Name:M
Last Name:O'DEA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CLARENDON AVE STE 470
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3475
Mailing Address - Country:US
Mailing Address - Phone:847-863-4196
Mailing Address - Fax:
Practice Address - Street 1:300 W CLARENDON AVE STE 470
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3475
Practice Address - Country:US
Practice Address - Phone:602-730-4450
Practice Address - Fax:602-391-2522
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.006898101YM0800X
AZLAC-20665101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health