=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053471359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERESA O. NDUKWE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 07/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 SOTOGRANDE DR
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75044-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-675-8188
-----------------------------------------------------
Fax | 972-530-2485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 SOTOGRANDE DR
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75044-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-675-8188
-----------------------------------------------------
Fax | 972-530-2485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | MRS. THERESA O. NDUKWE
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 972-675-8188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | NA
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------