Healthcare Provider Details

I. General information

NPI: 1083850259
Provider Name (Legal Business Name): MISS THERESA ABIMBOLA OGUNDIPE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14205 222ND ST 1ST FLOOR
LAURELTON NY
11413-3136
US

IV. Provider business mailing address

14205 222ND ST 1ST FLOOR
LAURELTON NY
11413-3136
US

V. Phone/Fax

Practice location:
  • Phone: 718-527-7661
  • Fax: 718-527-7661
Mailing address:
  • Phone: 718-527-7661
  • Fax: 718-527-7661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0179891
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: