Provider Demographics
NPI:1003313404
Name:EHABAHE, AIGBOVBOISE AYO
Entity Type:Individual
Prefix:
First Name:AIGBOVBOISE
Middle Name:AYO
Last Name:EHABAHE
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 1:850 W MARKET ST
Mailing Address - Street 2:415
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401
Mailing Address - Country:US
Mailing Address - Phone:786-357-5426
Mailing Address - Fax:
Practice Address - Street 1:850 W MARKET ST
Practice Address - Street 2:415
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401
Practice Address - Country:US
Practice Address - Phone:786-357-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCXXXXXXXXXXXXXX103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1003313404Medicaid
FL104576900Medicaid