Provider Demographics
NPI:1407376817
Name:EZEUGWU, YOLANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:
Last Name:EZEUGWU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-3608
Mailing Address - Country:US
Mailing Address - Phone:309-269-0306
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW AVE
Practice Address - Street 2:USA MEDDAC, RWBAHC
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490123981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical