Healthcare Provider Details

I. General information

NPI: 1336763325
Provider Name (Legal Business Name): OGHENEFEJIRO M ETIBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 W 19TH ST RM 3R
NEW YORK NY
10011-4238
US

IV. Provider business mailing address

5201 GREAT AMERICA PKWY STE 320
SANTA CLARA CA
95054
US

V. Phone/Fax

Practice location:
  • Phone: 510-712-0016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number148142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: