Provider Demographics
NPI:1871093260
Name:EZEH, IFEANYI GABRIEL
Entity type:Individual
Prefix:
First Name:IFEANYI
Middle Name:GABRIEL
Last Name:EZEH
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:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:LYFORD
Mailing Address - State:TX
Mailing Address - Zip Code:78569-0460
Mailing Address - Country:US
Mailing Address - Phone:956-437-1355
Mailing Address - Fax:
Practice Address - Street 1:8413 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:LYFORD
Practice Address - State:TX
Practice Address - Zip Code:78569
Practice Address - Country:US
Practice Address - Phone:956-437-1355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75334101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor