Provider Demographics
NPI:1558148395
Name:ODADA, CAROLYNE ATIENO
Entity Type:Individual
Prefix:
First Name:CAROLYNE
Middle Name:ATIENO
Last Name:ODADA
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 1:162 W 130TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-2181
Mailing Address - Country:US
Mailing Address - Phone:646-732-1931
Mailing Address - Fax:
Practice Address - Street 1:311 W 35TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1701
Practice Address - Country:US
Practice Address - Phone:212-736-5900
Practice Address - Fax:212-643-1441
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)