Provider Demographics
NPI:1922079045
Name:ODUOLA, EZEKIEL L (LCSW)
Entity Type:Individual
Prefix:
First Name:EZEKIEL
Middle Name:L
Last Name:ODUOLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 FEU FOLLET RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4234
Mailing Address - Country:US
Mailing Address - Phone:713-686-9194
Mailing Address - Fax:713-686-9413
Practice Address - Street 1:4411 DACOMA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-8611
Practice Address - Country:US
Practice Address - Phone:713-686-9194
Practice Address - Fax:713-686-9413
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX168821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117147203Medicaid
TX82N664Medicare PIN