Provider Demographics
NPI:1194275776
Name:HOUETOGNON, ODILE
Entity type:Individual
Prefix:
First Name:ODILE
Middle Name:
Last Name:HOUETOGNON
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 1:11944 TWINLAKES DR
Mailing Address - Street 2:APT 21
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3182
Mailing Address - Country:US
Mailing Address - Phone:240-353-9232
Mailing Address - Fax:
Practice Address - Street 1:11944 TWINLAKES DR
Practice Address - Street 2:APT 21
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-3182
Practice Address - Country:US
Practice Address - Phone:240-353-9232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12154172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker