Provider Demographics
NPI:1164225850
Name:UMUNNAKWE, FRED J (REGISTERED BEHAVIOR)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:J
Last Name:UMUNNAKWE
Suffix:
Gender:M
Credentials:REGISTERED BEHAVIOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 GREYTHORNE CMNS
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8103
Mailing Address - Country:US
Mailing Address - Phone:404-819-4992
Mailing Address - Fax:404-819-4992
Practice Address - Street 1:3190 NORTHEAST EXPY NE STE 110
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-5323
Practice Address - Country:US
Practice Address - Phone:404-487-6005
Practice Address - Fax:678-831-3005
Is Sole Proprietor?:No
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-264262106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician