Healthcare Provider Details

I. General information

NPI: 1518734748
Provider Name (Legal Business Name): FATUMA Y MNONGERWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST STE 245
BOISE ID
83705-1964
US

IV. Provider business mailing address

15564 FUCHSIA AVE
NAMPA ID
83651-5100
US

V. Phone/Fax

Practice location:
  • Phone: 208-570-4798
  • Fax:
Mailing address:
  • Phone: 208-570-4798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-44431
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: