Provider Demographics
NPI:1053544395
Name:OBONG, DAIZELL
Entity type:Individual
Prefix:MS
First Name:DAIZELL
Middle Name:
Last Name:OBONG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DAIZELL
Other - Middle Name:
Other - Last Name:OBONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4411 N CEDAR AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-2538
Mailing Address - Country:US
Mailing Address - Phone:559-248-1548
Mailing Address - Fax:559-248-1530
Practice Address - Street 1:4411 N CEDAR AVE STE 108
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-2538
Practice Address - Country:US
Practice Address - Phone:559-248-1548
Practice Address - Fax:559-248-1530
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)