Provider Demographics
NPI:1154168102
Name:OBOSE MENTAL HEALTH CLINIC
Entity type:Organization
Organization Name:OBOSE MENTAL HEALTH CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:AKHOASEGBE
Authorized Official - Last Name:EHICHIOYA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PMHNP-BC
Authorized Official - Phone:703-973-0176
Mailing Address - Street 1:1684 ROSEDALE CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3014
Mailing Address - Country:US
Mailing Address - Phone:703-973-0176
Mailing Address - Fax:
Practice Address - Street 1:1684 ROSEDALE CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3014
Practice Address - Country:US
Practice Address - Phone:703-973-0176
Practice Address - Fax:571-428-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty