Provider Demographics
NPI:1962256511
Name:EZENWA, EBENEZER
Entity type:Individual
Prefix:
First Name:EBENEZER
Middle Name:
Last Name:EZENWA
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 1:851 RANCH VISTA RD
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-7750
Mailing Address - Country:US
Mailing Address - Phone:951-403-8857
Mailing Address - Fax:
Practice Address - Street 1:URBAN RESTORATION
Practice Address - Street 2:1925 EUCLID AVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105
Practice Address - Country:US
Practice Address - Phone:951-403-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health