Provider Demographics
NPI:1619367489
Name:INDEPENDENT CONTRACTOR
Entity Type:Organization
Organization Name:INDEPENDENT CONTRACTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BSC
Authorized Official - Prefix:MR
Authorized Official - First Name:NWABUNWANNE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:OKAFOR
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MBA
Authorized Official - Phone:215-715-7999
Mailing Address - Street 1:9406 KREWSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3713
Mailing Address - Country:US
Mailing Address - Phone:215-464-2939
Mailing Address - Fax:
Practice Address - Street 1:9406 KREWSTOWN RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3713
Practice Address - Country:US
Practice Address - Phone:215-464-2939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002478251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health