Healthcare Provider Details

I. General information

NPI: 1487516290
Provider Name (Legal Business Name): OLUCHI AGAMEGWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12525 BAYBERRY CIR
CERRITOS CA
90703-7805
US

IV. Provider business mailing address

3067 W ORANGE AVE
ANAHEIM CA
92804-3156
US

V. Phone/Fax

Practice location:
  • Phone: 562-716-0074
  • Fax:
Mailing address:
  • Phone: 714-827-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: