Provider Demographics
NPI:1194312017
Name:MUNTWANAMBA, KHADIJA ALI (LCSW)
Entity type:Individual
Prefix:
First Name:KHADIJA
Middle Name:ALI
Last Name:MUNTWANAMBA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5413 HARVARD ST APT B
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3471
Mailing Address - Country:US
Mailing Address - Phone:817-566-5780
Mailing Address - Fax:
Practice Address - Street 1:5413 HARVARD ST APT B
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3471
Practice Address - Country:US
Practice Address - Phone:817-566-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-111881041C0700X
TX583461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical