Provider Demographics
NPI:1285014027
Name:EDEMIDIONG, ETTIENE
Entity Type:Individual
Prefix:MR
First Name:ETTIENE
Middle Name:
Last Name:EDEMIDIONG
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 1:4200 N MERIDIAN AVE
Mailing Address - Street 2:APT 433
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2628
Mailing Address - Country:US
Mailing Address - Phone:281-740-5572
Mailing Address - Fax:
Practice Address - Street 1:4200 N MERIDIAN AVE
Practice Address - Street 2:APT 433
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2628
Practice Address - Country:US
Practice Address - Phone:281-740-5572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-07
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health