Provider Demographics
NPI:1720480064
Name:ODUFUWA, KRISSHONDA ELAINE (MED, SLPA, BCBA)
Entity Type:Individual
Prefix:
First Name:KRISSHONDA
Middle Name:ELAINE
Last Name:ODUFUWA
Suffix:
Gender:F
Credentials:MED, SLPA, BCBA
Other - Prefix:
Other - First Name:KRISSHONDA
Other - Middle Name:ELAINE
Other - Last Name:ODUFUWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4230 FAIRWAY DR APT 4101
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-3275
Mailing Address - Country:US
Mailing Address - Phone:832-613-4417
Mailing Address - Fax:
Practice Address - Street 1:4230 FAIRWAY DR APT 4101
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010
Practice Address - Country:US
Practice Address - Phone:832-613-4417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX354922355S0801X
TX1958103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant