Provider Demographics
NPI:1124828819
Name:EMENOGU, ANI
Entity type:Individual
Prefix:
First Name:ANI
Middle Name:
Last Name:EMENOGU
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 ILYSSA WAY
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1377
Mailing Address - Country:US
Mailing Address - Phone:917-640-4536
Mailing Address - Fax:
Practice Address - Street 1:703 ILYSSA WAY
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1377
Practice Address - Country:US
Practice Address - Phone:917-640-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst