Provider Demographics
NPI:1821576323
Name:OKOLO, BRYAN
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:OKOLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1879 SANFORD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3845
Mailing Address - Country:US
Mailing Address - Phone:267-265-7292
Mailing Address - Fax:
Practice Address - Street 1:1879 SANFORD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3845
Practice Address - Country:US
Practice Address - Phone:267-265-7292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374700000XNursing Service Related ProvidersTechnician