Provider Demographics
NPI:1306802152
Name:MBANGAMOH, ERICA D (SLP)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:D
Last Name:MBANGAMOH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:D
Other - Last Name:POESCHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY RD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4298
Mailing Address - Country:US
Mailing Address - Phone:763-520-0419
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY RD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4298
Practice Address - Country:US
Practice Address - Phone:763-520-0419
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
434M7MBOtherBCBS MINNESOTA
HP55736OtherHEALTH PARTNERS