Basic Information
| Provider Information | |||||||||
| NPI: | 1790016319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MBONG | ||||||||
| FirstName: | UKPEANWAN | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC/LADC CANDIDATE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MBONG | ||||||||
| OtherFirstName: | UKPE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | UKPE MBONG | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 508 VERREAUX DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730728182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058012335 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2220 N CLASSEN BLVD | ||||||||
| Address2: | SUITE' E' | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731065809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055280087 | ||||||||
| FaxNumber: | 4055281802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2010 | ||||||||
| LastUpdateDate: | 01/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.