Provider Demographics
NPI:1093066110
Name:OMOWALE, MENTU
Entity Type:Individual
Prefix:MR
First Name:MENTU
Middle Name:
Last Name:OMOWALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4892 SAN PABLO DAM RD
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-3222
Mailing Address - Country:US
Mailing Address - Phone:510-236-0444
Mailing Address - Fax:
Practice Address - Street 1:4892 SAN PABLO DAM RD
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-3222
Practice Address - Country:US
Practice Address - Phone:510-236-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health