Provider Demographics
NPI:1003420142
Name:BOYD, ODETTE (PA)
Entity Type:Individual
Prefix:DR
First Name:ODETTE
Middle Name:
Last Name:BOYD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 FOOTHILL BLVD # 626
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3889
Mailing Address - Country:US
Mailing Address - Phone:424-230-9276
Mailing Address - Fax:
Practice Address - Street 1:5101 E LA PALMA AVE STE 100
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2056
Practice Address - Country:US
Practice Address - Phone:442-229-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-05
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94024879103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist