Provider Demographics
NPI:1043059710
Name:PRUSSIEN-OKAFOR, KEMAR VANINA (PHD)
Entity type:Individual
Prefix:DR
First Name:KEMAR
Middle Name:VANINA
Last Name:PRUSSIEN-OKAFOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KEMAR
Other - Middle Name:VANINA
Other - Last Name:PRUSSIEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3501 CIVIC CENTER BLVD # 3560-10
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3820
Mailing Address - Country:US
Mailing Address - Phone:267-854-6039
Mailing Address - Fax:
Practice Address - Street 1:3500 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4395
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical