MEDICARE: MR. CEDRIC ITA EYO LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	75651	TX

General Provider Information

NPI Number	:	1508349770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CEDRIC ITA EYO LPC

Provider Business Mailing Address
First Line	:	2526 BUSINESS CENTER DR APT 913
Second Line	:
City	:	PEARLAND
State	:	TX
Zip	:	77584-2433
Country	:	US
Telephone Number	:	832-775-6416
Fax Number	:

Provider Business Practice Location Address
First Line	:	14090 SOUTHWEST FWY STE 300
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77478-3679
Country	:	US
Telephone Number	:	346-375-7281
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/08/2023

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