Provider Demographics
NPI:1245929041
Name:AGBOR, FRED CLANCY ENOH
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:CLANCY ENOH
Last Name:AGBOR
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 1:308 NOVEL # A
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1793
Mailing Address - Country:US
Mailing Address - Phone:949-241-0023
Mailing Address - Fax:
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4507
Practice Address - Country:US
Practice Address - Phone:657-565-3259
Practice Address - Fax:833-706-4826
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY6808749106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician