Provider Demographics
NPI:1750909370
Name:IZUEGBUNAM, CHINEDU (LPC)
Entity type:Individual
Prefix:
First Name:CHINEDU
Middle Name:
Last Name:IZUEGBUNAM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:NEDU
Other - Middle Name:A
Other - Last Name:IZUEGBUNAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-0407
Mailing Address - Country:US
Mailing Address - Phone:860-450-7122
Mailing Address - Fax:
Practice Address - Street 1:54 NORTH ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2528
Practice Address - Country:US
Practice Address - Phone:860-450-7122
Practice Address - Fax:860-450-7127
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT46.004506101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional