Healthcare Provider Details

I. General information

NPI: 1619799863
Provider Name (Legal Business Name): OBIAGAELIAKU IBE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GRAMERCY AVE
TORRANCE CA
90501-3236
US

IV. Provider business mailing address

1240 E 124TH ST
LOS ANGELES CA
90059-3212
US

V. Phone/Fax

Practice location:
  • Phone: 714-617-4886
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number149988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: