Healthcare Provider Details

I. General information

NPI: 1104324664
Provider Name (Legal Business Name): DONATUS IKECHUKWU EZENNEKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 AUSTELL RD SW
MARIETTA GA
30008-4151
US

IV. Provider business mailing address

2122 AUSTELL RD SW
MARIETTA GA
30008-4151
US

V. Phone/Fax

Practice location:
  • Phone: 762-233-4869
  • Fax:
Mailing address:
  • Phone: 857-260-8805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: