Provider Demographics
NPI:1114516093
Name:ETUKE, EMMANUEL OGHENEKARO JR (LCPC)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:OGHENEKARO
Last Name:ETUKE
Suffix:JR
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 KILLARNEY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4124
Mailing Address - Country:US
Mailing Address - Phone:202-809-3928
Mailing Address - Fax:
Practice Address - Street 1:2750 KILLARNEY DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4124
Practice Address - Country:US
Practice Address - Phone:202-809-3928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC14862101YP2500X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional