Provider Demographics
NPI:1487932893
Name:EPIE, EMMANUEL ADE
Entity type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:ADE
Last Name:EPIE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:EMMANUEL
Other - Middle Name:ADE
Other - Last Name:EPIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1638 E GREENWAY RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5788
Mailing Address - Country:US
Mailing Address - Phone:602-481-9789
Mailing Address - Fax:602-268-1248
Practice Address - Street 1:7204 W PUEBLO AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-2037
Practice Address - Country:US
Practice Address - Phone:623-440-7423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ323P00000X
323P00000X
AZBH3872323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility