Provider Demographics
NPI:1427422658
Name:ONUBOGU, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ONUBOGU
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 1:243 AZALEA RD
Mailing Address - Street 2:
Mailing Address - City:BRODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322-7703
Mailing Address - Country:US
Mailing Address - Phone:570-994-6817
Mailing Address - Fax:
Practice Address - Street 1:243 AZALEA RD
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-7703
Practice Address - Country:US
Practice Address - Phone:570-994-6817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-27
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA26789126101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health