MEDICARE: NOCEBA MBANGATA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1265766596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOCEBA MBANGATA

Provider Business Mailing Address
First Line	:	2951 VANDERBIE ST
Second Line	:
City	:	LITTLE CANADA
State	:	MN
Zip	:	55117-1226
Country	:	US
Telephone Number	:	651-274-0018
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 VANDALIA ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1833
Country	:	US
Telephone Number	:	612-414-4730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2009
Last Update Date	:	09/18/2009

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Directions to “ NOCEBA MBANGATA ” Practice Location

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