Healthcare Provider Details

I. General information

NPI: 1295130870
Provider Name (Legal Business Name): MADU CASIMIR OHANENYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2014
Last Update Date: 10/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7629 WOODCREST AVE
PHILADELPHIA PA
19151-2703
US

IV. Provider business mailing address

7629 WOODCREST AVE
PHILADELPHIA PA
19151-2703
US

V. Phone/Fax

Practice location:
  • Phone: 267-471-1997
  • Fax:
Mailing address:
  • Phone: 267-471-1997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH001917
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: