Provider Demographics
NPI:1932817483
Name:OKELLO, LINDA AMONDI
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:AMONDI
Last Name:OKELLO
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 1:1711 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-9320
Mailing Address - Country:US
Mailing Address - Phone:843-934-2697
Mailing Address - Fax:
Practice Address - Street 1:1711 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-9320
Practice Address - Country:US
Practice Address - Phone:843-934-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRBT-22-243096Medicaid