Provider Demographics
NPI:1356795736
Name:IBIAM, OKWUKWE
Entity type:Individual
Prefix:
First Name:OKWUKWE
Middle Name:
Last Name:IBIAM
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 1:11 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-5528
Mailing Address - Country:US
Mailing Address - Phone:781-961-9481
Mailing Address - Fax:
Practice Address - Street 1:1640 REDSTONE CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7607
Practice Address - Country:US
Practice Address - Phone:781-937-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5292235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist