Provider Demographics
NPI:1912248402
Name:FADEYIBI, BRENDA PRINCE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:PRINCE
Last Name:FADEYIBI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:PRINCE
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 E 48TH ST
Mailing Address - Street 2:RM 801
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-1063
Mailing Address - Country:US
Mailing Address - Phone:212-421-1969
Mailing Address - Fax:212-223-0198
Practice Address - Street 1:1650 SELWYN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7626
Practice Address - Country:US
Practice Address - Phone:718-518-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63017537225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand