Provider Demographics
NPI:1437459229
Name:EZEALA, PRINCE O
Entity Type:Individual
Prefix:
First Name:PRINCE
Middle Name:O
Last Name:EZEALA
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 1:505 NE 46TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-3314
Mailing Address - Country:US
Mailing Address - Phone:405-270-0005
Mailing Address - Fax:
Practice Address - Street 1:1713 VICTORIA DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3860
Practice Address - Country:US
Practice Address - Phone:405-471-2298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor