Provider Demographics
NPI:1497636682
Name:BALEKE, KIBONGE
Entity type:Individual
Prefix:MR
First Name:KIBONGE
Middle Name:
Last Name:BALEKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8665 LAS VEGAS CT APT 3020
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-0057
Mailing Address - Country:US
Mailing Address - Phone:817-450-0048
Mailing Address - Fax:
Practice Address - Street 1:8665 LAS VEGAS CT APT 3020
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-0057
Practice Address - Country:US
Practice Address - Phone:817-450-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50411424101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty