Provider Demographics
NPI:1891288999
Name:AMEGAVI JOHNSON, KOSSIWA EDITH
Entity Type:Individual
Prefix:
First Name:KOSSIWA
Middle Name:EDITH
Last Name:AMEGAVI JOHNSON
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 1:2001 TALL TIMBERS LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-6543
Mailing Address - Country:US
Mailing Address - Phone:346-907-0003
Mailing Address - Fax:
Practice Address - Street 1:2001 TALL TIMBERS LN
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-6543
Practice Address - Country:US
Practice Address - Phone:346-907-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health