Provider Demographics
NPI:1427383090
Name:ABIOLA, MATILDA ABIMBOLA (PT)
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:ABIMBOLA
Last Name:ABIOLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1592 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5218
Mailing Address - Country:US
Mailing Address - Phone:917-412-0190
Mailing Address - Fax:718-251-4365
Practice Address - Street 1:1592 E 91ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5218
Practice Address - Country:US
Practice Address - Phone:917-412-0190
Practice Address - Fax:718-251-4365
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015651-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist