Provider Demographics
NPI:1316517709
Name:UMEH, OGENNA AGATHA
Entity type:Individual
Prefix:MRS
First Name:OGENNA
Middle Name:AGATHA
Last Name:UMEH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:OGENNA
Other - Middle Name:AGATHA
Other - Last Name:OFFODILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3510 PORTAGE RD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-6091
Practice Address - Country:US
Practice Address - Phone:574-252-7225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014167A225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty