Provider Demographics
NPI:1194491035
Name:ADEGBEMBO, ALEXANDER ANTHONY (COTA)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ANTHONY
Last Name:ADEGBEMBO
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 SKILLMAN ST APT 2323
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-8463
Mailing Address - Country:US
Mailing Address - Phone:469-360-1777
Mailing Address - Fax:
Practice Address - Street 1:3225 WOODLAND PARK DR APT 1742
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-7618
Practice Address - Country:US
Practice Address - Phone:469-360-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217042224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant