Provider Demographics
NPI:1184900839
Name:OHAERI, NNAMDI GLENN SR (PSYD)
Entity type:Individual
Prefix:DR
First Name:NNAMDI
Middle Name:GLENN
Last Name:OHAERI
Suffix:SR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3376
Mailing Address - Country:US
Mailing Address - Phone:909-730-6218
Mailing Address - Fax:
Practice Address - Street 1:USS ABRAHAM LINCOLN
Practice Address - Street 2:CVN 72 UNIT 100349
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09520
Practice Address - Country:US
Practice Address - Phone:909-730-6218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004342103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program