Healthcare Provider Details

I. General information

NPI: 1063903433
Provider Name (Legal Business Name): EZINWANNE OKORAFOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41521 W 11 MILE RD
NOVI MI
48375-1803
US

IV. Provider business mailing address

1853 MICHESTER DR
WEST BLOOMFIELD MI
48324-1138
US

V. Phone/Fax

Practice location:
  • Phone: 248-299-0030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: