Healthcare Provider Details

I. General information

NPI: 1497292189
Provider Name (Legal Business Name): ADAKU STACEY NWAGBARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 N CHARLES ST
TOWSON MD
21204-3780
US

IV. Provider business mailing address

1239 DOVER DR
SAN BERNARDINO CA
92407-2901
US

V. Phone/Fax

Practice location:
  • Phone: 443-809-4130
  • Fax:
Mailing address:
  • Phone: 909-499-6447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number09579
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: