MEDICARE: IME MARCELLA EKONG PSYD

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	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760906382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IME MARCELLA EKONG PSYD

Provider Business Mailing Address
First Line	:	6511 NOVA DR # 176
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33317-7401
Country	:	US
Telephone Number	:	954-465-4177
Fax Number	:

Provider Business Practice Location Address
First Line	:	6511 NOVA DR # 176
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33317-7401
Country	:	US
Telephone Number	:	954-465-4177
Fax Number	:

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

Provider Enumeration Date	:	07/26/2017
Last Update Date	:	12/11/2020

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Directions to “ IME MARCELLA EKONG PSYD” Practice Location

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