Provider Demographics
NPI:1215776216
Name:MBOUP, DIENABOU
Entity type:Individual
Prefix:
First Name:DIENABOU
Middle Name:
Last Name:MBOUP
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 1:11105 XENIA AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3492
Mailing Address - Country:US
Mailing Address - Phone:763-291-1207
Mailing Address - Fax:
Practice Address - Street 1:7205 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3134
Practice Address - Country:US
Practice Address - Phone:612-208-0729
Practice Address - Fax:612-354-3801
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician