Provider Demographics
NPI:1366289209
Name:MODIBA, KHUTSO ANNAH (BACHELOR)
Entity type:Individual
Prefix:
First Name:KHUTSO
Middle Name:ANNAH
Last Name:MODIBA
Suffix:
Gender:F
Credentials:BACHELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W BALTIMORE AVE APT 7B
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1848
Mailing Address - Country:US
Mailing Address - Phone:661-496-2789
Mailing Address - Fax:
Practice Address - Street 1:2400 KINGSTON CT
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-3650
Practice Address - Country:US
Practice Address - Phone:813-776-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0C009705225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation