Provider Demographics
NPI:1417687765
Name:OBAGBEMI, SOJI
Entity Type:Individual
Prefix:
First Name:SOJI
Middle Name:
Last Name:OBAGBEMI
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 1:3920 W CHARLESTON BLVD STE N
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1651
Mailing Address - Country:US
Mailing Address - Phone:170-282-2044
Mailing Address - Fax:
Practice Address - Street 1:3920 W CHARLESTON BLVD STE N
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1651
Practice Address - Country:US
Practice Address - Phone:702-822-0447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20181610830Medicaid