Provider Demographics
NPI:1760258446
Name:IFULU, KETIA
Entity Type:Individual
Prefix:
First Name:KETIA
Middle Name:
Last Name:IFULU
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 1:23286 RICHARDS RD APT 11306
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77445-4279
Mailing Address - Country:US
Mailing Address - Phone:972-801-8190
Mailing Address - Fax:
Practice Address - Street 1:700 MILAM ST STE 1300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-2736
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician