MEDICARE: SHAMISO SAMANTHA MADZONGANYIKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1013420850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAMISO SAMANTHA MADZONGANYIKA

Provider Business Mailing Address
First Line	:	9779 DENALI CIR
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-6259
Country	:	US
Telephone Number	:	916-880-6474
Fax Number	:

Provider Business Practice Location Address
First Line	:	9779 DENALI CIR
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-6259
Country	:	US
Telephone Number	:	916-880-6474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2017
Last Update Date	:	11/15/2017

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Directions to “ SHAMISO SAMANTHA MADZONGANYIKA ” Practice Location

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