Provider Demographics
NPI:1104415405
Name:IMANI MENTAL HEALTH AND WELLNESS LLC
Entity type:Organization
Organization Name:IMANI MENTAL HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:MBUGUA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:214-458-1713
Mailing Address - Street 1:12063 SW TAYLOR CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5845
Mailing Address - Country:US
Mailing Address - Phone:214-458-1713
Mailing Address - Fax:
Practice Address - Street 1:3939 NE HANCOCK ST # 202
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5321
Practice Address - Country:US
Practice Address - Phone:214-458-1713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-12
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty