Provider Demographics
NPI:1952664112
Name:NWOKE, THEODORE
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:NWOKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10010 SPRING VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-3304
Mailing Address - Country:US
Mailing Address - Phone:916-599-5525
Mailing Address - Fax:
Practice Address - Street 1:12755 N HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-9323
Practice Address - Country:US
Practice Address - Phone:209-340-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2013-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 75087106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist