Healthcare Provider Details

I. General information

NPI: 1962918276
Provider Name (Legal Business Name): GILBERT UCHENNA OKONKWO JR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9805 MARRIOTTSVILLE RD
RANDALLSTOWN MD
21133-2414
US

IV. Provider business mailing address

9805 MARRIOTTSVILLE RD
RANDALLSTOWN MD
21133-2414
US

V. Phone/Fax

Practice location:
  • Phone: 443-985-0580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB463751
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: