Provider Demographics
NPI:1952075442
Name:IWUCHUKWU GODSLAW, THELMA OBIAGALIAKU (OTR/L)
Entity Type:Individual
Prefix:
First Name:THELMA
Middle Name:OBIAGALIAKU
Last Name:IWUCHUKWU GODSLAW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:THELMA
Other - Middle Name:
Other - Last Name:IWUCHUKWU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:3505 W 139TH ST APT 42
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-7734
Mailing Address - Country:US
Mailing Address - Phone:424-240-0813
Mailing Address - Fax:
Practice Address - Street 1:4867 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5969
Practice Address - Country:US
Practice Address - Phone:424-240-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22573225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22573OtherOCCUPATIONAL THERAPY LICENSE
456730OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY CERTICATION