Provider Demographics
NPI:1720743990
Name:AGBO, GODWIN IKECHUKWU
Entity Type:Individual
Prefix:
First Name:GODWIN
Middle Name:IKECHUKWU
Last Name:AGBO
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 1:203 EAST ST
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-1234
Mailing Address - Country:US
Mailing Address - Phone:413-667-7839
Mailing Address - Fax:
Practice Address - Street 1:203 EAST ST
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1234
Practice Address - Country:US
Practice Address - Phone:413-667-7839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily