Healthcare Provider Details

I. General information

NPI: 1235235151
Provider Name (Legal Business Name): STACEY SUDIE EZEKWE LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SHAPE HEALTHCARE FACILITY UNIT 21414 BOX 116
APO AE
09705
BE

IV. Provider business mailing address

SHAPE HEALTHCARE FACILITY UNIT 21414 BOX 116
APO AE
09705
BE

V. Phone/Fax

Practice location:
  • Phone: 0113265445801
  • Fax: 0113265445809
Mailing address:
  • Phone: 0113265445801
  • Fax: 0113265445809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1787
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: