Provider Demographics
NPI:1952430514
Name:EKONG, RAPHAEL PATRICK
Entity Type:Individual
Prefix:MR
First Name:RAPHAEL
Middle Name:PATRICK
Last Name:EKONG
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 1:215 SETH CT
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3638
Mailing Address - Country:US
Mailing Address - Phone:843-642-1492
Mailing Address - Fax:
Practice Address - Street 1:3236 LANDMARK DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-8488
Practice Address - Country:US
Practice Address - Phone:843-642-1492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional