Provider Demographics
NPI:1538880349
Name:EGBO, AMAZILO M
Entity type:Individual
Prefix:
First Name:AMAZILO
Middle Name:M
Last Name:EGBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMA
Other - Middle Name:M
Other - Last Name:EGBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 S MACGREGOR WAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-1032
Mailing Address - Country:US
Mailing Address - Phone:713-702-6323
Mailing Address - Fax:
Practice Address - Street 1:2800 S MACGREGOR WAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-1032
Practice Address - Country:US
Practice Address - Phone:713-741-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1090340363LP0808X
TX103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent