Provider Demographics
NPI:1104324664
Name:EZENNEKA, DONATUS IKECHUKWU
Entity type:Individual
Prefix:
First Name:DONATUS
Middle Name:IKECHUKWU
Last Name:EZENNEKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 AUSTELL RD SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4151
Mailing Address - Country:US
Mailing Address - Phone:857-260-8805
Mailing Address - Fax:
Practice Address - Street 1:2122 AUSTELL RD SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4151
Practice Address - Country:US
Practice Address - Phone:762-233-4869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty