Provider Demographics
NPI:1780187914
Name:EZIKE, KORLU (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KORLU
Middle Name:
Last Name:EZIKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 RIDGE PIKE
Mailing Address - Street 2:
Mailing Address - City:EAGLEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19403-5708
Mailing Address - Country:US
Mailing Address - Phone:610-630-2111
Mailing Address - Fax:610-630-4003
Practice Address - Street 1:1220 SUGARBERRY LN
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-2886
Practice Address - Country:US
Practice Address - Phone:267-246-2687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0101221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA665666Medicaid