Provider Demographics
NPI:1336613751
Name:DURUNNA, ADAEZE EZINNE
Entity type:Individual
Prefix:
First Name:ADAEZE
Middle Name:EZINNE
Last Name:DURUNNA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1382 BLUE OAKS BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-7052
Mailing Address - Country:US
Mailing Address - Phone:877-412-8031
Mailing Address - Fax:
Practice Address - Street 1:1382 BLUE OAKS BLVD STE 213
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-7052
Practice Address - Country:US
Practice Address - Phone:877-412-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health