Provider Demographics
NPI:1265812473
Name:ABIMBOLA, OLANREWAJU (COTA)
Entity type:Individual
Prefix:
First Name:OLANREWAJU
Middle Name:
Last Name:ABIMBOLA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:OLANREWAJU
Other - Middle Name:
Other - Last Name:ABIMBOLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:4200 E COMMERCE WAY
Mailing Address - Street 2:#213
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-9634
Mailing Address - Country:US
Mailing Address - Phone:916-662-2548
Mailing Address - Fax:
Practice Address - Street 1:4200 E COMMERCE WAY
Practice Address - Street 2:#213
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-9634
Practice Address - Country:US
Practice Address - Phone:916-662-2548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2587224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant