Provider Demographics
NPI:1366257685
Name:ESSOBOU, AYISSATOU
Entity type:Individual
Prefix:
First Name:AYISSATOU
Middle Name:
Last Name:ESSOBOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9706 JEFFERSON PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-3269
Mailing Address - Country:US
Mailing Address - Phone:531-375-1848
Mailing Address - Fax:402-991-5070
Practice Address - Street 1:9706 JEFFERSON PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-3269
Practice Address - Country:US
Practice Address - Phone:402-557-8583
Practice Address - Fax:402-991-5070
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities