Provider Demographics
NPI:1306158712
Name:MBODJI, EL HADJI MALICK
Entity type:Individual
Prefix:
First Name:EL HADJI
Middle Name:MALICK
Last Name:MBODJI
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 1:12200 HERITAGE PARK RD
Mailing Address - Street 2:279
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5995
Mailing Address - Country:US
Mailing Address - Phone:405-413-9619
Mailing Address - Fax:
Practice Address - Street 1:3621 N KELLEY AVE
Practice Address - Street 2:100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-4520
Practice Address - Country:US
Practice Address - Phone:405-524-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)