Provider Demographics
NPI:1558776914
Name:MOMODU, ANITA AISHA OBEHI
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:AISHA OBEHI
Last Name:MOMODU
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 1:8615 ISLA VISTA VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-7521
Mailing Address - Country:US
Mailing Address - Phone:702-325-9756
Mailing Address - Fax:
Practice Address - Street 1:8615 ISLA VISTA VALLEY CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-7521
Practice Address - Country:US
Practice Address - Phone:702-325-9756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No251S00000XAgenciesCommunity/Behavioral Health