Healthcare Provider Details

I. General information

NPI: 1568610822
Provider Name (Legal Business Name): CHARLES ODIPO ED. D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3067 FREEPORT BLVD
SACRAMENTO CA
95818-4347
US

IV. Provider business mailing address

3067 FREEPORT BLVD
SACRAMENTO CA
95818-4347
US

V. Phone/Fax

Practice location:
  • Phone: 916-217-7529
  • Fax: 916-229-0689
Mailing address:
  • Phone: 916-217-7529
  • Fax: 916-229-0689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY19345
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: