Provider Demographics
NPI:1346432705
Name:NGWADOM, ALPHONSUS EKELE (LPC)
Entity Type:Individual
Prefix:
First Name:ALPHONSUS
Middle Name:EKELE
Last Name:NGWADOM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 ADAMS POINT DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-6507
Mailing Address - Country:US
Mailing Address - Phone:919-247-2312
Mailing Address - Fax:
Practice Address - Street 1:65 GLEN RD
Practice Address - Street 2:SUITE 295
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-7943
Practice Address - Country:US
Practice Address - Phone:919-247-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 101YA0400X
NC9669101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9583Medicaid