Provider Demographics
NPI:1598479255
Name:ODEBIYI, TUNMISE
Entity Type:Individual
Prefix:
First Name:TUNMISE
Middle Name:
Last Name:ODEBIYI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9307 S 51ST AVE UNIT 29
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-3903
Mailing Address - Country:US
Mailing Address - Phone:623-329-7459
Mailing Address - Fax:
Practice Address - Street 1:5202 W PECAN RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2460
Practice Address - Country:US
Practice Address - Phone:623-329-7459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDDH3686320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities