Provider Demographics
NPI:1093837288
Name:IBIKUNLE, ADETOKUNBO ADETUTU (MS OTR L)
Entity Type:Individual
Prefix:MRS
First Name:ADETOKUNBO
Middle Name:ADETUTU
Last Name:IBIKUNLE
Suffix:
Gender:F
Credentials:MS OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FAIRHILL ROAD
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-1804
Mailing Address - Country:US
Mailing Address - Phone:610-649-3255
Mailing Address - Fax:610-649-2289
Practice Address - Street 1:300 FAIRHILL ROAD
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-1804
Practice Address - Country:US
Practice Address - Phone:610-649-3255
Practice Address - Fax:610-649-2289
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009438225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist