Provider Demographics
NPI:1497208045
Name:OMOFUMA, YIMI (MA, PHD)
Entity Type:Individual
Prefix:
First Name:YIMI
Middle Name:
Last Name:OMOFUMA
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:YIMI
Other - Middle Name:ISIMEMEN
Other - Last Name:OMOFUMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, PHD
Mailing Address - Street 1:2161 NW MILITARY HWY STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1844
Mailing Address - Country:US
Mailing Address - Phone:210-447-6363
Mailing Address - Fax:
Practice Address - Street 1:2161 NW MILITARY HWY STE 207
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1844
Practice Address - Country:US
Practice Address - Phone:210-447-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program