Provider Demographics
NPI:1275128852
Name:OBAMEDO, AIZEYOSABO F (OTR/L)
Entity Type:Individual
Prefix:
First Name:AIZEYOSABO
Middle Name:F
Last Name:OBAMEDO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 ARNET AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7601
Mailing Address - Country:US
Mailing Address - Phone:908-265-2911
Mailing Address - Fax:
Practice Address - Street 1:961 ARNET AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7601
Practice Address - Country:US
Practice Address - Phone:908-265-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025371225X00000X
NJ46TR00971600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist