Provider Demographics
NPI:1417403379
Name:ABEBE, ESTIFANOS
Entity Type:Individual
Prefix:
First Name:ESTIFANOS
Middle Name:
Last Name:ABEBE
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 1:1826 RACHEL LANE
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664
Mailing Address - Country:US
Mailing Address - Phone:512-246-3556
Mailing Address - Fax:
Practice Address - Street 1:1826 RACHEL LN
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7455
Practice Address - Country:US
Practice Address - Phone:512-246-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141177320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities