Healthcare Provider Details

I. General information

NPI: 1508349770
Provider Name (Legal Business Name): CEDRIC ITA EYO LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14090 SOUTHWEST FWY STE 300
SUGAR LAND TX
77478-3679
US

IV. Provider business mailing address

2526 BUSINESS CENTER DR APT 913
PEARLAND TX
77584-2433
US

V. Phone/Fax

Practice location:
  • Phone: 346-375-7281
  • Fax:
Mailing address:
  • Phone: 832-775-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number75651
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: