Healthcare Provider Details

I. General information

NPI: 1265832331
Provider Name (Legal Business Name): INYANG UDO-EMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 04/05/2025
Certification Date: 04/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5112 S 6TH ST
PHOENIX AZ
85040-2291
US

IV. Provider business mailing address

5112 S 6TH ST
PHOENIX AZ
85040-2291
US

V. Phone/Fax

Practice location:
  • Phone: 480-744-3288
  • Fax:
Mailing address:
  • Phone: 480-744-3288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-13859
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-16539
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: