1841803780 NPI number — MRS. ALISA REBECCA DENILSON IKENWUDE LPC

Table of content: MRS. ALISA REBECCA DENILSON IKENWUDE LPC (NPI 1841803780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841803780 NPI number — MRS. ALISA REBECCA DENILSON IKENWUDE LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENILSON IKENWUDE
Provider First Name:
ALISA
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLEMONS
Provider Other First Name:
ALISA
Provider Other Middle Name:
REBECCA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841803780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29155 NORTHWESTERN HWY #652
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
284-890-5807
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AL THANYA STREET 685, BUILDING 163, ZONE 54, FLAT 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEHAIRJA
Provider Business Practice Location Address State Name:
DOHA
Provider Business Practice Location Address Postal Code:
00000
Provider Business Practice Location Address Country Code:
QA
Provider Business Practice Location Address Telephone Number:
974-316-1274
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  6401012289 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 6401222447 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)