Provider Demographics
NPI:1639754617
Name:EMMANGELIC, EPIPHANY NTAKI
Entity Type:Individual
Prefix:
First Name:EPIPHANY
Middle Name:NTAKI
Last Name:EMMANGELIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 S LAKE ERIE DR STE B
Mailing Address - Street 2:
Mailing Address - City:W VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-7351
Mailing Address - Country:US
Mailing Address - Phone:385-441-4900
Mailing Address - Fax:
Practice Address - Street 1:2655 S LAKE ERIE DR STE B
Practice Address - Street 2:
Practice Address - City:W VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-7351
Practice Address - Country:US
Practice Address - Phone:385-441-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty