Provider Demographics
NPI:1538866595
Name:OKAFOR -AGILO, LYDIA JANE
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:JANE
Last Name:OKAFOR -AGILO
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 1:17067 JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4926
Mailing Address - Country:US
Mailing Address - Phone:310-902-5733
Mailing Address - Fax:
Practice Address - Street 1:10626 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6329
Practice Address - Country:US
Practice Address - Phone:310-902-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8385225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation