Provider Demographics
NPI:1528313947
Name:EBUA, WILFRED WALLANG
Entity type:Individual
Prefix:
First Name:WILFRED
Middle Name:WALLANG
Last Name:EBUA
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 1:1905 ARAPAHOE CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:64034-8636
Mailing Address - Country:US
Mailing Address - Phone:816-419-1294
Mailing Address - Fax:
Practice Address - Street 1:1905 ARAPAHOE CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MO
Practice Address - Zip Code:64034-8636
Practice Address - Country:US
Practice Address - Phone:816-419-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities