Provider Demographics
NPI:1912453689
Name:ODONGO, RENATA (AT,CKTP CGT)
Entity type:Individual
Prefix:
First Name:RENATA
Middle Name:
Last Name:ODONGO
Suffix:
Gender:F
Credentials:AT,CKTP CGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 S. VAL VISTA DR.
Mailing Address - Street 2:APT 2089
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6447
Mailing Address - Country:US
Mailing Address - Phone:816-262-1979
Mailing Address - Fax:
Practice Address - Street 1:4710 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1738
Practice Address - Country:US
Practice Address - Phone:816-262-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer