Provider Demographics
NPI:1467121731
Name:OTUBAGA, MONIOLUWA (DPT)
Entity Type:Individual
Prefix:
First Name:MONIOLUWA
Middle Name:
Last Name:OTUBAGA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2002 W GRAND PKWY N STE 125
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-2518
Practice Address - Country:US
Practice Address - Phone:281-710-9001
Practice Address - Fax:281-697-6703
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1345683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist