Provider Demographics
NPI:1316212749
Name:TENKAPOWOM, KOWANDA
Entity Type:Individual
Prefix:
First Name:KOWANDA
Middle Name:
Last Name:TENKAPOWOM
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 1:3347 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3574
Mailing Address - Country:US
Mailing Address - Phone:706-432-7893
Mailing Address - Fax:706-432-3780
Practice Address - Street 1:3421 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-432-7893
Practice Address - Fax:706-432-3780
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606317BMedicaid
GAGRP 2010Medicare PIN