Provider Demographics
NPI:1760630412
Name:EZEMA, KINGSLEY
Entity Type:Individual
Prefix:
First Name:KINGSLEY
Middle Name:
Last Name:EZEMA
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 1:4800 BURT MAR DR
Mailing Address - Street 2:APT. F3
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-9570
Mailing Address - Country:US
Mailing Address - Phone:706-615-8317
Mailing Address - Fax:
Practice Address - Street 1:421 12TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2522
Practice Address - Country:US
Practice Address - Phone:706-494-7776
Practice Address - Fax:706-494-7076
Is Sole Proprietor?:No
Enumeration Date:2008-09-07
Last Update Date:2008-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical