Provider Demographics
NPI:1205591435
Name:ERHUNMWUNSEE, KINGSLEY EGHOSA
Entity type:Individual
Prefix:MR
First Name:KINGSLEY
Middle Name:EGHOSA
Last Name:ERHUNMWUNSEE
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 1:4442 ARTHUR KILL RD STE 4
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1321
Mailing Address - Country:US
Mailing Address - Phone:718-412-3170
Mailing Address - Fax:
Practice Address - Street 1:273 HERBERTON AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303
Practice Address - Country:US
Practice Address - Phone:718-412-3170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY237091329Medicaid