Provider Demographics
NPI:1164129003
Name:EJISOBY, IHUOMA JOYCE
Entity Type:Individual
Prefix:
First Name:IHUOMA
Middle Name:JOYCE
Last Name:EJISOBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 GOLF RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1952
Mailing Address - Country:US
Mailing Address - Phone:870-288-4760
Mailing Address - Fax:
Practice Address - Street 1:3136 GOLF RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1952
Practice Address - Country:US
Practice Address - Phone:870-288-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician