Healthcare Provider Details

I. General information

NPI: 1700497385
Provider Name (Legal Business Name): ISIOMA DEBORAH OKONKWO RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/16/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10015 OLD COLUMBIA RD STE B215
COLUMBIA MD
21046-1865
US

IV. Provider business mailing address

3704 KAYSON ST
SILVER SPRING MD
20906-5128
US

V. Phone/Fax

Practice location:
  • Phone: 443-566-9422
  • Fax:
Mailing address:
  • Phone: 443-570-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-94414
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: