Provider Demographics
NPI:1144975178
Name:MBIPEH, JUNIOR FORMUKONG (COTA/L)
Entity type:Individual
Prefix:
First Name:JUNIOR
Middle Name:FORMUKONG
Last Name:MBIPEH
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NORTHWEST 135TH WAY
Mailing Address - Street 2:BLDG. 46 APT 301
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325
Mailing Address - Country:US
Mailing Address - Phone:214-986-0857
Mailing Address - Fax:
Practice Address - Street 1:3500 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-4101
Practice Address - Country:US
Practice Address - Phone:610-359-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18734224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant