Provider Demographics
NPI:1497292189
Name:NWAGBARA, ADAKU STACEY
Entity Type:Individual
Prefix:
First Name:ADAKU
Middle Name:STACEY
Last Name:NWAGBARA
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 1:1239 DOVER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2901
Mailing Address - Country:US
Mailing Address - Phone:909-499-6447
Mailing Address - Fax:
Practice Address - Street 1:6901 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-3780
Practice Address - Country:US
Practice Address - Phone:443-809-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MD09579225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician