Provider Demographics
NPI:1639713738
Name:DUCKLAND HOMES LLC
Entity Type:Organization
Organization Name:DUCKLAND HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:OGHENETEGA
Authorized Official - Last Name:OTTAN-OBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-842-2852
Mailing Address - Street 1:1906 DRIVER GREEN LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-2340
Mailing Address - Country:US
Mailing Address - Phone:248-842-2852
Mailing Address - Fax:
Practice Address - Street 1:1906 DRIVER GREEN LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-2340
Practice Address - Country:US
Practice Address - Phone:248-842-2852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10812201100001OtherAETNA