Provider Demographics
NPI:1417426990
Name:IGIEBOR, OSARUESE
Entity Type:Individual
Prefix:
First Name:OSARUESE
Middle Name:
Last Name:IGIEBOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20212 REDWOOD RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4324
Mailing Address - Country:US
Mailing Address - Phone:510-422-2090
Mailing Address - Fax:
Practice Address - Street 1:20212 REDWOOD RD STE 201
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4324
Practice Address - Country:US
Practice Address - Phone:510-422-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician