Healthcare Provider Details

I. General information

NPI: 1699499806
Provider Name (Legal Business Name): FORTUNE AISABOKHAE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18414 STABLEWOOD MANOR TRL
RICHMOND TX
77407-2324
US

IV. Provider business mailing address

17117 WESTHEIMER RD # 6
HOUSTON TX
77082-1259
US

V. Phone/Fax

Practice location:
  • Phone: 832-545-7352
  • Fax:
Mailing address:
  • Phone: 832-545-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: