Healthcare Provider Details

I. General information

NPI: 1487577987
Provider Name (Legal Business Name): SHANIKA MOMBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 THUNDER CIR
BENSALEM PA
19020-2163
US

IV. Provider business mailing address

346 THUNDER CIR
BENSALEM PA
19020-2163
US

V. Phone/Fax

Practice location:
  • Phone: 609-508-6493
  • Fax:
Mailing address:
  • Phone: 609-508-6493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number15BC00400700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: