Provider Demographics
NPI:1144829706
Name:ETUKUDOH, DICKSON INNEMESET
Entity type:Individual
Prefix:
First Name:DICKSON
Middle Name:INNEMESET
Last Name:ETUKUDOH
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 1:9797 LEAWOOD BLVD APT 608
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-2666
Mailing Address - Country:US
Mailing Address - Phone:713-538-0774
Mailing Address - Fax:
Practice Address - Street 1:21630 MERCHANTS WAY STE 200
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-2514
Practice Address - Country:US
Practice Address - Phone:281-253-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216510224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant