Provider Demographics
NPI:1346618105
Name:EGBUZIEM-ANDERSON, IHUOMA JACQUELINE
Entity Type:Individual
Prefix:
First Name:IHUOMA
Middle Name:JACQUELINE
Last Name:EGBUZIEM-ANDERSON
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 1:4441 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3604
Mailing Address - Country:US
Mailing Address - Phone:559-600-9171
Mailing Address - Fax:
Practice Address - Street 1:4441 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT117659106H00000X
CAIMF78283106H00000X
CALMFT133192106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAMFT117659OtherREGISTERED ASSOCIATE MARRIAGE AND FAMILY THERAPIST
CAIMF78283OtherMARRIAGE AND FAMILY THERAPIST INTERN
CA133192OtherLICENSED MARRIAGE AND FAMILY THERAPIST