Healthcare Provider Details

I. General information

NPI: 1316212749
Provider Name (Legal Business Name): KOWANDA TENKAPOWOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

3347 RAVENWOOD DR
AUGUSTA GA
30907-3574
US

V. Phone/Fax

Practice location:
  • Phone: 706-432-7893
  • Fax: 706-432-3780
Mailing address:
  • Phone: 706-432-7893
  • Fax: 706-432-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: