Provider Demographics
NPI:1235846940
Name:GBONGO, SEIBATU MARILYN
Entity Type:Individual
Prefix:
First Name:SEIBATU
Middle Name:MARILYN
Last Name:GBONGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12106 WESTLOCK PL
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2422
Mailing Address - Country:US
Mailing Address - Phone:240-260-8656
Mailing Address - Fax:
Practice Address - Street 1:12106 WESTLOCK PL
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-2422
Practice Address - Country:US
Practice Address - Phone:240-260-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator