Provider Demographics
NPI:1336781541
Name:MUTOMBO-HARRIS, MICHELINE
Entity Type:Individual
Prefix:
First Name:MICHELINE
Middle Name:
Last Name:MUTOMBO-HARRIS
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 1:3233 HENNEPIN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4264
Mailing Address - Country:US
Mailing Address - Phone:612-559-4942
Mailing Address - Fax:
Practice Address - Street 1:3548 BRYANT AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4119
Practice Address - Country:US
Practice Address - Phone:612-822-8227
Practice Address - Fax:612-825-4205
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN272671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical