Provider Demographics
NPI:1164048138
Name:KABANDA, NANTUME (SCC-C)
Entity type:Individual
Prefix:
First Name:NANTUME
Middle Name:
Last Name:KABANDA
Suffix:
Gender:F
Credentials:SCC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 GRAND AVE # 1
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-1223
Mailing Address - Country:US
Mailing Address - Phone:732-874-0156
Mailing Address - Fax:
Practice Address - Street 1:19 GRAND AVE # 1
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-1223
Practice Address - Country:US
Practice Address - Phone:732-874-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 261QC1500X, 101YP1600X
TX397129034101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
123070526901OtherAETNA
NJNONEMedicaid
123070526901OtherAETNA