Healthcare Provider Details

I. General information

NPI: 1356294367
Provider Name (Legal Business Name): AUGUSTINE THABO SHIJA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2026
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 N 16TH ST STE K
COUNCIL BLUFFS IA
51501-0109
US

IV. Provider business mailing address

110 S 35TH ST
COUNCIL BLUFFS IA
51501-3286
US

V. Phone/Fax

Practice location:
  • Phone: 712-256-4420
  • Fax:
Mailing address:
  • Phone: 319-595-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number136048
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: