Provider Demographics
NPI:1013420850
Name:MADZONGANYIKA, SHAMISO SAMANTHA
Entity Type:Individual
Prefix:
First Name:SHAMISO
Middle Name:SAMANTHA
Last Name:MADZONGANYIKA
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 1:9779 DENALI CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-6259
Mailing Address - Country:US
Mailing Address - Phone:916-880-6474
Mailing Address - Fax:
Practice Address - Street 1:9779 DENALI CIR
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-6259
Practice Address - Country:US
Practice Address - Phone:916-880-6474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician