Provider Demographics
NPI:1659796191
Name:MBONGO, SIMON NFOSAK (LVN)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:NFOSAK
Last Name:MBONGO
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:SIMON
Other - Middle Name:NFOSAK
Other - Last Name:MBONGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:1583 MARIETTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-2136
Mailing Address - Country:US
Mailing Address - Phone:408-800-9276
Mailing Address - Fax:
Practice Address - Street 1:2001 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1136
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN211623101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health