Provider Demographics
NPI:1194180133
Name:OMUYEH, GOODLUCK
Entity Type:Individual
Prefix:
First Name:GOODLUCK
Middle Name:
Last Name:OMUYEH
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 1:110 POWELL LN
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-3310
Mailing Address - Country:US
Mailing Address - Phone:610-350-1727
Mailing Address - Fax:
Practice Address - Street 1:110 POWELL LN
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-3310
Practice Address - Country:US
Practice Address - Phone:610-350-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst