Basic Information
| Provider Information | |||||||||
| NPI: | 1023403847 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BAMFO | ||||||||
| FirstName: | NANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2008 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
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| Address1: | 2008 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 85006 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 106H00000X | 05 | CA | MEDICAID |