Provider Demographics
NPI:1568610822
Name:ODIPO, CHARLES (ED D)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ODIPO
Suffix:
Gender:M
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3067 FREEPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-4347
Mailing Address - Country:US
Mailing Address - Phone:916-217-7529
Mailing Address - Fax:916-229-0689
Practice Address - Street 1:3067 FREEPORT BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-4347
Practice Address - Country:US
Practice Address - Phone:916-217-7529
Practice Address - Fax:916-229-0689
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19345103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral