Provider Demographics
NPI:1962178749
Name:MBUKPA, EDEM
Entity type:Individual
Prefix:
First Name:EDEM
Middle Name:
Last Name:MBUKPA
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 1:2103 PURPLE MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-2730
Mailing Address - Country:US
Mailing Address - Phone:347-301-1918
Mailing Address - Fax:
Practice Address - Street 1:2103 PURPLE MARTIN DR
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423-2730
Practice Address - Country:US
Practice Address - Phone:347-301-1918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215948224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant