Provider Demographics
NPI:1821413071
Name:ODETOYE, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:ODETOYE
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 1:16870 W WOODLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-6054
Mailing Address - Country:US
Mailing Address - Phone:623-925-8606
Mailing Address - Fax:
Practice Address - Street 1:16870 W WOODLANDS AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6054
Practice Address - Country:US
Practice Address - Phone:623-925-8606
Practice Address - Fax:623-925-8606
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4441103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ461868645Medicaid