Provider Demographics
NPI:1144788258
Name:NORTHRIDGE BEHAVIORAL HEALTH PLLC
Entity Type:Organization
Organization Name:NORTHRIDGE BEHAVIORAL HEALTH PLLC
Other - Org Name:NORTHRIDGE BEHAVIORAL HEALTH PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:IJEOMA
Authorized Official - Middle Name:C
Authorized Official - Last Name:AJUFO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-681-0575
Mailing Address - Street 1:2829 BABCOCK RD STE 126
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6009
Mailing Address - Country:US
Mailing Address - Phone:440-681-0575
Mailing Address - Fax:
Practice Address - Street 1:2829 BABCOCK RD STE 126
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6009
Practice Address - Country:US
Practice Address - Phone:440-681-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3856486-01Medicaid