Healthcare Provider Details

I. General information

NPI: 1245865849
Provider Name (Legal Business Name): OGBULORIE OKORIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PARKER AVE
RODEO CA
94572-1400
US

IV. Provider business mailing address

2400 E KATELLA AVE STE 800
ANAHEIM CA
92806-5955
US

V. Phone/Fax

Practice location:
  • Phone: 510-245-4300
  • Fax:
Mailing address:
  • Phone: 714-858-3590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: