Provider Demographics
NPI:1760672133
Name:ENCABO, JOSELITO ESTOQUE (OTR)
Entity Type:Individual
Prefix:
First Name:JOSELITO
Middle Name:ESTOQUE
Last Name:ENCABO
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8423 BREMEN WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-8305
Mailing Address - Country:US
Mailing Address - Phone:260-490-5090
Mailing Address - Fax:
Practice Address - Street 1:2827 NORTHGATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-2903
Practice Address - Country:US
Practice Address - Phone:260-492-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003538A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1555-656Medicaid