Provider Demographics
NPI:1194369264
Name:EKUGWUM, SIMEON SOBENNA
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:SOBENNA
Last Name:EKUGWUM
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 1:18 ROB LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-5927
Mailing Address - Country:US
Mailing Address - Phone:601-842-0971
Mailing Address - Fax:
Practice Address - Street 1:2439 MANHATTAN BLVD STE 308
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-5396
Practice Address - Country:US
Practice Address - Phone:504-366-5265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9826101YP2500X
171M00000X, 343900000X, 347C00000X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker