Provider Demographics
NPI:1376253393
Name:AYELE, IMRAN ABUBAKER
Entity Type:Individual
Prefix:
First Name:IMRAN
Middle Name:ABUBAKER
Last Name:AYELE
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 1:2553 KATE BOND RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-5107
Mailing Address - Country:US
Mailing Address - Phone:901-247-8738
Mailing Address - Fax:
Practice Address - Street 1:4075 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-7400
Practice Address - Country:US
Practice Address - Phone:901-584-8281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-22-242428106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician