Provider Demographics
NPI:1144877481
Name:MADUNA, BONISWA PORTIA
Entity type:Individual
Prefix:
First Name:BONISWA
Middle Name:PORTIA
Last Name:MADUNA
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 1:8000 COOK RD APT 1109
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77072-3939
Mailing Address - Country:US
Mailing Address - Phone:832-805-0933
Mailing Address - Fax:
Practice Address - Street 1:8000 COOK RD APT 1109
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-3939
Practice Address - Country:US
Practice Address - Phone:832-805-0933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4212092Medicaid