Healthcare Provider Details

I. General information

NPI: 1003723628
Provider Name (Legal Business Name): MARIAM SENGHORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 ADVENTURELAND DR STE B
ALTOONA IA
50009-2237
US

IV. Provider business mailing address

1625 ADVENTURELAND DR STE B
ALTOONA IA
50009-2237
US

V. Phone/Fax

Practice location:
  • Phone: 515-967-4369
  • Fax:
Mailing address:
  • Phone: 515-967-4369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB2760454
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: