Provider Demographics
NPI:1669012142
Name:EZEPUE, IFEOMA E (CDCA)
Entity type:Individual
Prefix:MRS
First Name:IFEOMA
Middle Name:E
Last Name:EZEPUE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:MRS
Other - First Name:IFEOMA
Other - Middle Name:E
Other - Last Name:IBEKWE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:20120 ARDWELL DR
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1802
Mailing Address - Country:US
Mailing Address - Phone:216-749-2246
Mailing Address - Fax:
Practice Address - Street 1:5209 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3703
Practice Address - Country:US
Practice Address - Phone:216-749-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.172126101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.172126OtherCHEMICAL DEPENDENCY PROFESSIONALS BOARD