Provider Demographics
NPI:1336022722
Name:IMARAH, ERUKOGHENE
Entity type:Individual
Prefix:
First Name:ERUKOGHENE
Middle Name:
Last Name:IMARAH
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 1:6505 SHILOH RD STE 1100
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-8405
Mailing Address - Country:US
Mailing Address - Phone:678-648-7644
Mailing Address - Fax:
Practice Address - Street 1:6505 SHILOH RD STE 1100
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-8405
Practice Address - Country:US
Practice Address - Phone:678-648-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-25-423673106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician