Provider Demographics
NPI:1932678547
Name:ITOE, ERIC ETONGWE
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ETONGWE
Last Name:ITOE
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 1:2811 PENNSYLVANIA AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3865
Mailing Address - Country:US
Mailing Address - Phone:202-894-6811
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
459CCB3106E00000X
251S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
70937973OtherDC ALLIANCE