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General NPI Number Information
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NPI Number | 1043582646
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Entity Type | Individual
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Provider Name | SIMON IBEZIMCHI UDEMGBA PH.D.
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Gender | Male
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Dates
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Enumeration Date | 01/30/2012
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Last Update Date | 05/31/2013
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Provider Practice Location Address
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Address Line | 401 NEW KARNER RD BRANDON PLACE
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City | ALBANY
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State | NY
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Zip | 12205-3840
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Country | US
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Telephone | 518-456-3614
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Fax |
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Provider Business Mailing Address
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Address Line | 523 MICHIGAN AVE
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City | SCHENECTADY
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State | NY
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Zip | 12303-1313
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Country | US
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Telephone | 518-374-5336
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 005435
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License Number State | NY
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