Provider Demographics
NPI:1689902546
Name:EKWEGH, EDMOND N (COUNSELOR)
Entity Type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:N
Last Name:EKWEGH
Suffix:
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12713 FONTHILL AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-4776
Mailing Address - Country:US
Mailing Address - Phone:323-359-8266
Mailing Address - Fax:
Practice Address - Street 1:12713 FONTHILL AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-4776
Practice Address - Country:US
Practice Address - Phone:323-359-8266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA778655467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)