Basic Information
| Provider Information | |||||||||
| NPI: | 1346618105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EGBUZIEM-ANDERSON | ||||||||
| FirstName: | IHUOMA | ||||||||
| MiddleName: | JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4441 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596009171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4441 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596009171 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2015 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT117659 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | IMF78283 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | LMFT133192 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | AMFT117659 | 01 | CA | REGISTERED ASSOCIATE MARRIAGE AND FAMILY THERAPIST | OTHER | IMF78283 | 01 | CA | MARRIAGE AND FAMILY THERAPIST INTERN | OTHER | 133192 | 01 | CA | LICENSED MARRIAGE AND FAMILY THERAPIST | OTHER |