Provider Demographics
NPI:1740980945
Name:ODAGBODO, OMOTAYO
Entity type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:
Last Name:ODAGBODO
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 1:3625 MARTIN LUTHER KING JR AVE SE APT 1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1509
Mailing Address - Country:US
Mailing Address - Phone:202-904-9903
Mailing Address - Fax:
Practice Address - Street 1:3625 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1509
Practice Address - Country:US
Practice Address - Phone:202-904-9903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty