Provider Demographics
NPI:1710712120
Name:IBHAWA, OSAZE BATHOLOMEW
Entity type:Individual
Prefix:
First Name:OSAZE
Middle Name:BATHOLOMEW
Last Name:IBHAWA
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 1:779 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2608
Mailing Address - Country:US
Mailing Address - Phone:716-322-9088
Mailing Address - Fax:
Practice Address - Street 1:779 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2608
Practice Address - Country:US
Practice Address - Phone:347-781-4214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014352101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health