Provider Demographics
NPI:1386418606
Name:AJIBADE, TAIWO A
Entity type:Individual
Prefix:
First Name:TAIWO
Middle Name:A
Last Name:AJIBADE
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 1:8052 MATTERHORN LN APT D118
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1153
Mailing Address - Country:US
Mailing Address - Phone:708-501-1704
Mailing Address - Fax:
Practice Address - Street 1:1316 N TIBBS AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-3024
Practice Address - Country:US
Practice Address - Phone:317-835-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003209A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant