Provider Demographics
NPI:1699499806
Name:AISABOKHAE, FORTUNE
Entity type:Individual
Prefix:
First Name:FORTUNE
Middle Name:
Last Name:AISABOKHAE
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 1:17117 WESTHEIMER RD # 6
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-1259
Mailing Address - Country:US
Mailing Address - Phone:832-545-7352
Mailing Address - Fax:
Practice Address - Street 1:18414 STABLEWOOD MANOR TRL
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2324
Practice Address - Country:US
Practice Address - Phone:832-545-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty