Provider Demographics
NPI:1992335442
Name:IDIONG, KUFREABASI
Entity type:Individual
Prefix:MR
First Name:KUFREABASI
Middle Name:
Last Name:IDIONG
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 1:28795 CEDAR BROOK LN
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7471
Mailing Address - Country:US
Mailing Address - Phone:760-583-5174
Mailing Address - Fax:
Practice Address - Street 1:39990 FAURE RD
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-9408
Practice Address - Country:US
Practice Address - Phone:951-708-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW90638104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker