| Doctor Name: | OBATALA OMBU |
| NPI Number: | 1184969347 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.A. |
| License Number: | |
| Business Practice Address: | 209 Short St Kingstree, SC - 295563926 |
| Business Phone Number: | 8433725959 |
| Business Fax Number: | 8433557746 |
| Mailing Address: | Po Box 697, KINGSTREE |
| State: | SC |
| Postal Code: | 295560697 |
| Phone Number: | 8433552772 |
| Fax Number: | 8433557746 |
| NPI Enumeration Date: | 11/29/2012 |
| NPI Last Update Date: | 11/29/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TF0200X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Forensic |
| Taxonomy Definition: | |