Healthcare Provider Details

I. General information

NPI: 1013733484
Provider Name (Legal Business Name): KEN UGOCHUKWU-OKONKWO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN
DALLAS TX
75230-2571
US

IV. Provider business mailing address

7777 FOREST LN
DALLAS TX
75230-2571
US

V. Phone/Fax

Practice location:
  • Phone: 972-465-9878
  • Fax:
Mailing address:
  • Phone: 972-465-9878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KEN UGOCHUKWU-OKONKWO
Title or Position: COMMUNITY PSYCHOLOGIST
Credential: CMHP
Phone: 945-296-9255