Provider Demographics
NPI:1093278921
Name:EGBUZIEM, KELECHI MICHELLE (COTA)
Entity Type:Individual
Prefix:
First Name:KELECHI
Middle Name:MICHELLE
Last Name:EGBUZIEM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6477 N MARIPOSA ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-3817
Mailing Address - Country:US
Mailing Address - Phone:559-259-9305
Mailing Address - Fax:
Practice Address - Street 1:5555 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-6006
Practice Address - Country:US
Practice Address - Phone:559-430-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant