Provider Demographics
NPI:1700909694
Name:OMOLE, BEVERLY NKEMDIRIM
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:NKEMDIRIM
Last Name:OMOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 TRAILSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-2184
Mailing Address - Country:US
Mailing Address - Phone:562-405-5215
Mailing Address - Fax:
Practice Address - Street 1:1211 TRAILSIDE CIR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-2184
Practice Address - Country:US
Practice Address - Phone:562-405-5215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA11599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health